Insomnia

What is insomnia?

Insomnia is when you aren’t sleeping as you should. That can mean you aren’t sleeping enough, you aren’t sleeping well or you’re having trouble falling or staying asleep. For some people, insomnia is a minor inconvenience. For others, insomnia can be a major disruption. The reasons why insomnia happens can vary just as widely.

Your body needs sleep for many reasons (and science is still unlocking an understanding of why sleep is so important to your body). Experts do know that when you don’t sleep enough, it can cause sleep deprivation, which is usually unpleasant (at the very least) and keeps you from functioning at your best.

How sleep needs and habits vary and what that means for you

Sleep habits and needs can be very different from person to person. Because of these variations, experts consider a wide range of sleep characteristics “normal.” Some examples of this include:

• Early birds/early risers: Some people naturally prefer to go to bed and wake up early.
• Night owls/late risers: Some people prefer to go to bed and wake up late.
• Short-sleepers: Some people naturally need less sleep than others. Research indicates that there may even be a genetic reason for that.
• Learned sleep differences: Some people develop sleep habits for specific reasons, such as their profession. Military personnel with combat experience often learn to be light sleepers because of the demands and dangers of their profession. On the opposite end of that spectrum, some people learn to be very heavy sleepers so they can still sleep despite surrounding noises.
• Natural changes in sleep needs: Your need for sleep changes throughout your life. Infants need significantly more sleep, between 14 and 17 hours per day, while adults (ages 18 and up) need about seven to nine hours per day.

Types of insomnia

There are two main ways that experts use to put insomnia into categories:

• Time: Experts classify insomnia as acute (short-term) or chronic (long-term). The chronic form is known as insomnia disorder.
• Cause: Primary insomnia means it happens on its own. Secondary insomnia means it’s a symptom of another condition or circumstance.

How common is insomnia?

Both the acute and chronic forms of insomnia are very common. Roughly, 1 in 3 adults worldwide have insomnia symptoms, and about 10% of adults meet the criteria for insomnia disorder.

What are the symptoms of insomnia?

Insomnia has several potential symptoms, which fall into a few categories:

• When you have trouble sleeping.
• Daytime effects.
• Chronic insomnia characteristics.

When you have trouble sleeping

When you have trouble sleeping is an important symptom of insomnia. There are three main ways this happens, and people commonly shift between them over time:

• Initial (sleep onset) insomnia: This means you have trouble falling asleep.
• Middle (maintenance) insomnia: This form makes you wake up in the middle of the night but you fall back asleep. It’s the most common form, affecting almost two-thirds of people with insomnia.
• Late (early waking) insomnia: This form means you wake up too early in the morning and don’t fall back asleep.

Daytime effects

Because you need sleep to be your best, disruptions like insomnia commonly cause symptoms that affect you while you’re awake. These include:

• Feeling tired, unwell or sleepy.
• Delayed responses, such as reacting too slowly when you’re driving.
• Trouble remembering things.
• Slowed thought processes, confusion or trouble concentrating.
• Mood disruptions, especially anxiety, depression and irritability.
• Other disruptions in your work, social activities, hobbies or other routine activities.

Chronic insomnia characteristics

The characteristics of insomnia symptoms are also important. If your symptoms have certain characteristics, you may have chronic insomnia. The characteristics include:

• Circumstances: A chronic insomnia diagnosis requires insomnia without circumstances that would interfere with your ability to sleep (such as changes in work schedule, life events, etc.). Diagnosing insomnia requires having sleep difficulties despite having time and the right environment to do so.
• Frequency: Chronic insomnia requires you to have insomnia frequently, at least three times per week.
• Duration: Chronic insomnia lasts for at least three months.
• Explanation: The insomnia isn’t happening because of substances or medications (including both medical and nonmedical drugs) or other sleep disorders. Other medical or mental health conditions also can’t fully explain why you’re not sleeping.

What causes the condition?

Experts don’t fully know why insomnia happens, but the current understanding is that this condition can involve many factors. Some of these factors could be causes or they could simply contribute to it. More research is necessary to understand exactly how and why insomnia happens.

The factors that could cause or contribute include (but aren’t limited to) the following:

• Family history (genetics): Sleep traits and conditions, including insomnia, seem to run in families.
• Brain activity differences: People with insomnia may have more active brains or brain chemistry differences that affect their ability to sleep.
• Medical conditions:Your physical health can affect your ability to sleep. This includes temporary illnesses like minor infections or injuries, or chronic conditions like acid reflux or Parkinson’s disease. Conditions that affect your circadian rhythm, your body’s natural sleep/wake clock, are also factors.
• Mental health conditions: About half the people with chronic insomnia also have at least one other mental health condition, like anxiety or depression.
• Life circumstances:Stressful or difficult life circumstances may not necessarily cause insomnia, but it’s very common for them to contribute to it.
• Life changes: Brief or temporary changes are often factors, including jet lag, sleeping in an unfamiliar place or adjusting to a new work schedule (especially shift work). Long-term changes, like moving to a new home, can also affect sleep.
• Your habits and routine: Your sleep habits (also known as sleep hygiene) can contribute to insomnia. That includes whether or not you take naps, when you go to sleep, if and when you consume caffeine, and other habits.

What are the risk factors for insomnia?

Insomnia is also more likely to happen in people with the following characteristics or circumstances:

• Light sleepers.
• People who use alcohol.
• People who don’t feel safe in their homes (such as situations involving repeated violence or abuse).
• People with fear or anxiety about sleep, such as those with disruptive sleep issues like nocturnal panic attacks or nightmare disorder.

What are the complications of this condition?

When insomnia is severe or lasts a long time, it causes sleep deprivation. A major concern with sleep deprivation is daytime sleepiness, which can be dangerous if you’re driving or doing other tasks that require you to be alert and attentive.

Sleep deprivation can also increase the risk of certain conditions:

• Depression.
• Anxiety.
• High blood pressure (hypertension).
• Heart attack.
• Stroke.
• Obstructive sleep apnea.
• Type 2 diabetes.
• Obesity.
• Conditions that involve psychosis.

How is insomnia diagnosed?

A healthcare provider can diagnose insomnia using a combination of methods, especially by asking you questions about your health history, personal circumstances, sleep habits, symptoms and more. They may also recommend certain tests to rule out other conditions that could cause or contribute to insomnia.

What tests will be done to diagnose insomnia?

There aren’t any tests that can diagnose insomnia directly. Instead, tests help rule out other conditions with similar symptoms to insomnia. The most likely tests include:

• Sleep apnea testing involving an overnight sleep study in a sleep lab (polysomnography) or an at-home sleep apnea screening device.
• Actigraphy.
• Multiple sleep latency test (MSLT).

Other tests are also possible depending on your symptoms and other factors. Your healthcare provider is the best person to tell you what tests they recommend.

How is insomnia treated, and is there a cure?

There are many ways to treat insomnia, ranging from simple changes in your lifestyle and habits to various medications. The main approaches to treating insomnia are:

• Developing and practicing good sleep habits (also known as sleep hygiene).
• Medications that help you fall or stay asleep (especially ones that aren’t habit-forming or that might otherwise affect your sleep).
• Mental healthcare.

Medications that help you fall or stay asleep

Many different types of medications can help you fall or stay asleep. Many of these are sedative or hypnotic drugs — both prescription and nonprescription — as well as mental health medications, and certain herbs and supplements.

• Sedative drugs: These get their name from a Latin word that means “to settle.” They reduce nervous system activity.
• Hypnotic drugs: These get their name from Hypnos, the Greek god of sleep. These make you sleepy.

In general, your healthcare provider is the best person to tell you about the possible treatments and which they recommend for you. They’re also the best source of information about the possible side effects or complications with treatments.

The following information contains examples of medications, but it isn’t a list of every treatment available. Remember that medications that treat insomnia may not help everyone. Some medications can interact with others, and your age and physical health play a role, too.

It’s also important to keep in mind that while medications can help you sleep, some may also negatively affect your sleep cycle. Sleep quality, not just quantity, is important. That means you should use medications — even over-the-counter ones — cautiously.

Prescription drugs for insomnia

Several prescription drug types can treat insomnia. Depending on your location, some medications might have legal restrictions because of how they work or their effects.

Controlled drug types include:

• Benzodiazepines: Examples include estazolam, quazepam (Doral®), temazepam (Restoril®) and triazolam (Halcion®).
• “Z-drugs” (experts often group these with benzodiazepines despite the name because they have very similar properties): The most common of these include eszopiclone (Lunesta®), zaleplon (Sonata®) and zolpidem (Ambien®).
• Dual orexin receptor antagonists (DORAs): Orexin is a wake-promoting chemical in your brain. Blocking orexin helps make you sleepy. Examples of these include suvorexant (Belsomra®), lemborexant (Dayvigo®) and daridorexant (Quviviq®).
• Antiseizure medications: These include gabapentin (Neurontin®) and pregabalin (Lyrica®), which can help with conditions like restless leg syndrome, which can keep you awake.

Noncontrolled drug types include:

• Sedating antidepressants: These include tricyclic antidepressant (TCA) drugs like doxepin (Silenor®) and amitriptyline (Elavil®), and trazodone.
• Melatonin and related drugs: Melatonin is a chemical your brain uses that tells you it’s time to go to sleep. It can come in prescription strength and lower strengths are available over the counter*. There are also synthetic drugs that work similarly to melatonin, including ramelteon (Rozerem®).

*NOTE: Don’t take more than the recommended amount of melatonin without first talking to your healthcare provider. Doses above 10 milligrams may be harmful.

Nonprescription drugs for insomnia

Antihistamine drugs, which treat allergies, can also make you sleepy. Examples of this include diphenhydramine (the active ingredient in drugs like Benadryl®) and doxylamine (commonly known under the brand name Unisom®).

Herbs and supplements

Many herbs or supplements can help treat insomnia. While many of these are common and well-known, it’s best not to assume that an herb or supplement is automatically safe for you. You should talk to a healthcare provider about herbs and supplements before taking them. That helps you avoid possible side effects or interactions, especially if you have any medical conditions or take any other medications.

Mental healthcare

Because your mental health can greatly affect your ability to sleep, mental healthcare is one of the most effective ways to improve your sleep, either directly or indirectly. A healthcare provider is the best person to tell you more about the possible mental health options and provide you with resources on how to get this kind of care.

Can insomnia be prevented, or can I lower my risk of having it?

Some causes of insomnia are preventable, while others can happen for reasons that aren’t well understood. While it’s impossible to prevent insomnia entirely, there are many things you can do to help yourself sleep better (see below under “Living With” for more information about what you can do to avoid insomnia or reduce how it affects you).

What can I expect if I have insomnia, and what’s the outlook for this condition?

Insomnia usually isn’t a major concern. Most people who experience insomnia may feel tired or not quite their best the next day, but that feeling often gets better once you do get enough quality sleep. Chronic insomnia is disruptive. While it usually isn’t dangerous, it can still negatively affect your life in many ways.

If you notice you’re having symptoms of sleep deprivation, it’s a good idea to talk to a healthcare provider. They can look for possible causes for why you’re not sleeping. They can also offer guidance and treatment that can help you sleep better.

How long does insomnia last?

Short-term insomnia is insomnia that you have for under three months. Chronic insomnia lasts more than three months.

The causes of insomnia can vary widely, meaning how long you have insomnia can also change and shift over time. Your healthcare provider can tell you more about your insomnia and what you can do to limit how it affects you.

How do I take care of myself?

Some of the most important things you can do to help your insomnia — and your sleep overall — revolve around sleep hygiene. These include, but aren’t limited to:

• Set and follow a sleep schedule. For most people, the best thing you can do for your body and sleep needs is to have a routine. Have a bedtime and keep to it as closely as possible, including on weekends, holidays, vacations, etc. Try not to rely on napping, and avoid naps in the late afternoon or early evening, as these can affect your sleep cycle.
• Give yourself time to wind down. Put aside the concerns of the day before bedtime as best you can. Build in a buffer time between when you finish for the day and when you go to bed. That can help you get in the right frame of mind for sleep. If you can't fall asleep, try to do something relaxing or calming rather than remaining awake in bed.
• Get comfortable. Feeling comfortable is very important if you want to get quality sleep. Set your sleeping environment accordingly, including lighting, sounds and temperature. Some people prefer sleeping with a sound generator that plays a specific part of the sound spectrum, and you may want to try this, too.
• Put that device down. Electronic devices typically use types of light that trick your brain into thinking it’s not nighttime. That can disrupt the release of chemicals that tell your brain and body that it’s time to sleep.
• Mind what you eat or drink. Eating or drinking too much and/or too late in the evening can affect your ability to sleep. Eating or drinking certain things can also affect your sleep, especially nicotine products or things that contain caffeine or alcohol.
• Stay active. Physical activity, even just walking, can help you get better quality sleep.
• If you consistently have trouble sleeping, talk to your healthcare provider. Your primary care provider is a good resource to help you understand why you aren’t sleeping and help you work on improving how you sleep. They can also help detect any health issues that might affect your ability to sleep.

When should I see my healthcare provider, and when should I seek care?

You should talk to your healthcare provider (especially a primary care provider) if you notice that insomnia lasts more than a few nights and/or if it starts to affect your daily routine, tasks and activities. You should also talk to them if you notice the following:

• Sleepiness during your waking hours that’s hard to resist.
• Brief instances where you fall asleep during waking hours (these are known as microsleeps), especially if they happen while you’re working or driving.
• If you have other conditions, including mental health conditions or concerns, that affect how much or how well you sleep.

What questions should I ask my doctor?

• Is my physical health affecting my sleep, and could I have symptoms or another condition keeping me from sleeping?
• How are my medications (if you take any) affecting my sleep?
• What can I do if I think my mental health is affecting how I sleep?

Can being pregnant affect how I sleep?

Yes, being pregnant (and conditions that happen while you’re pregnant) can significantly affect your ability to sleep. Being pregnant commonly causes changes throughout your body, including physical, hormonal and psychological effects. Those can affect your sleep routine and make it harder to get enough quality sleep. If you’re pregnant and notice you’re having issues sleeping, it’s important to talk to your healthcare provider. They can often help you better understand why you aren’t sleeping well and what you can do to help yourself.

Can COVID-19 cause insomnia?

Yes, COVID-19 can affect how you sleep, but experts still don’t fully understand how or why it does that. Researchers are investigating how exactly COVID-19 affects both your brain and your body. They also think that the overall stress related to the COVID-19 pandemic may play a role in this.