Insomnia

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    Marina Shkayeva

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    Last Updated: May 25, 2023

    Insomnia is a common sleep condition which involves trouble falling asleep, staying asleep, or both. The resulting insufficient or poor-quality sleep can lead to worsened quality of life and functional impairments.

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    Insomnia falls under the Sleep category.

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    What is insomnia?

    Insomnia is a common sleep disorder comprising low-quality sleep or not enough sleep due to trouble initiating sleep and/or maintaining sleep. Insomnia can be short term (lasting days or weeks) or chronic (lasting 3 months or longer).[1] Insomnia occurs in 10-15% of the general population, with a greater prevalence in women during and after menopause, as well as older adults. In fact, up to 50% of older adults report insomnia or sleep disturbances.[2][3]

    How much sleep should I get?

    What are the main signs and symptoms of insomnia?

    Some symptoms of insomnia include:[1]

    • Lying awake for a long time before being able to fall asleep
    • Only sleeping for short periods of time
    • Staying awake throughout most of the night
    • Feeling unrested or unrefreshed after sleep
    • Involuntarily waking up too early

    How is insomnia diagnosed?

    A healthcare provider will diagnose insomnia by taking a detailed medical history, including many questions about sleep habits. A physical exam is done to rule out other medical or mental conditions that can cause difficulty sleeping. Sometimes sleep studies can be performed to arrive at an accurate diagnosis. Insomnia is characterized as “chronic” when sleep problems occur at least 3 nights per week for at least 3 months.[2]

    What is the Pittsburgh Sleep Quality Index (PSQI)?

    What are some of the main medical treatments for insomnia?

    Medication treatments for insomnia are indicated for improving sleep onset, sleep maintenance, or both. Examples of medications with evidence of benefit for insomnia include orexin receptor antagonists (suvorexant), nonbenzodiazepine hypnotics (eszopiclone Lunesta, zolpidem Ambien, zaleplon Sonata), certain benzodiazepines (triazolam, temazepam), melatonin agonists (ramelteon Rozerem), and certain antidepressants (doxepin Silenor). Although medications such as trazodone, tiagabine, and diphenhydramine are commonly used, experts do not recommend them for chronic insomnia due to potential harms and inadequate evidence of benefit.[4]

    Have any supplements been studied for insomnia?

    Supplements studied for insomnia include melatonin, valerian root, kava-kava, chamomile, lavender, and many others. These supplements have sedating effects and can increase relaxation and induce sleep in some people with short-term insomnia.[3] There is much less research on supplements for chronic insomnia.[4]

    Is there any evidence regarding melatonin toxicity, tolerance, and addiction?

    How could diet affect insomnia?

    A common therapeutic approach for alleviating insomnia is maintaining sleep hygiene, a part of which involves diet. Sleep hygiene techniques include not eating too much at night and not eating too late into the night. It also includes avoiding or limiting the intake of alcohol, caffeine, and caffeine-containing foods and drinks (e.g., coffee, tea, and chocolate), especially when it is close to bedtime. Following a healthy, nutrient-rich diet (e.g., high in fruits and vegetables, low in refined sugar) is also considered a part of maintaining good sleep hygiene.[3][2][5]

    How exactly might caffeine mess up my circadian rhythm?

    How does alcohol affect my sleep?

    Are there any other treatments for insomnia?

    For short-term insomnia, sleep hygiene techniques which involve adjusting lifestyle factors (e.g., diet, exercise) and environmental factors (e.g., light, noise, temperature) is commonly recommended, however, sleep hygiene is not recommended as a solo treatment for chronic insomnia. For chronic insomnia, cognitive behavioral therapy (CBT) has good evidence of benefit, especially when used in combination with other therapies. Sleep hygiene and CBT are usually recommended in combination with other behavioral treatments such as sleep restriction, relaxation therapy, and stimulus control.[6]

    What should you avoid doing before bed?

    What causes insomnia?

    Common causes of insomnia include work stress, relationship issues, or traumatic events. Often times, insomnia occurs in response to certain medical conditions, medicines, and other sleep disorders (e.g., obstructive sleep apnea). Caffeine, tobacco, alcohol, and other substances can also trigger insomnia. However, in some cases, insomnia is considered to be a primary problem because it does not have an identifiable cause, although risk factors include long-lasting emotional upset, stress, travel, and shift work.[1]

    How does sun exposure influence sleep?

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    Frequently asked questions

    What is insomnia?

    Insomnia is a common sleep disorder comprising low-quality sleep or not enough sleep due to trouble initiating sleep and/or maintaining sleep. Insomnia can be short term (lasting days or weeks) or chronic (lasting 3 months or longer).[1] Insomnia occurs in 10-15% of the general population, with a greater prevalence in women during and after menopause, as well as older adults. In fact, up to 50% of older adults report insomnia or sleep disturbances.[2][3]

    How much sleep should I get?

    How much sleep you need may take some trial-and-error testing to see what works best. But if you’re looking for some general guidelines, check out the recommendations from the National Sleep Foundation below.[18]

    AGERECOMMENDEDMAY BE APPROPRIATENOT RECOMMENDED
    0–3 months14–1711–19< 11 or > 19
    4–11 months12–1510–18< 10 or > 18
    1–2 years11–149–16< 9 or > 16
    3–5 years10–138–14< 8 or > 14
    6–13 years9–117–12< 7 or > 12
    14–17 years8–107–11< 7 or > 11
    18–25 years7–96–11< 6 or > 11
    26–64 years7–96–10< 6 or > 10
    ≥65 years7–85– 9< 5 or > 9

    Adapted from Hirshkowitz et al. Sleep Health. 2015.[18]

    What are the main signs and symptoms of insomnia?

    Some symptoms of insomnia include:[1]

    • Lying awake for a long time before being able to fall asleep
    • Only sleeping for short periods of time
    • Staying awake throughout most of the night
    • Feeling unrested or unrefreshed after sleep
    • Involuntarily waking up too early
    How is insomnia diagnosed?

    A healthcare provider will diagnose insomnia by taking a detailed medical history, including many questions about sleep habits. A physical exam is done to rule out other medical or mental conditions that can cause difficulty sleeping. Sometimes sleep studies can be performed to arrive at an accurate diagnosis. Insomnia is characterized as “chronic” when sleep problems occur at least 3 nights per week for at least 3 months.[2]

    What is the Pittsburgh Sleep Quality Index (PSQI)?

    The Pittsburgh Sleep Quality Index (PSQI) is a short self-report questionnaire and the most widely used subjective measure of sleep quality.[36] The PSQI consists of 24 questions or items measuring seven dimensions from 0 (best) to 3 (worst). These seven factors can be broadly categorized into sleep efficiency factors (sleep quality, sleep latency, sleep duration, and habitual sleep efficiency) and sleep disturbance factors (sleep disturbance, use of sleep medications, and daytime disturbance).

    For example, sleep duration of more than 7 hours scores 0, while sleeping less than 5 hours is a score of 3. Adding up the average scores of the seven factors gives a global PSQI score from 0 to 21, with 0–4 indicating “good” sleep and 5–21 indicating “poor” sleep. This subjective and straightforward measure of sleep quality may seem oversimplified. However, a review found that, besides being short and practical for clinical and non-clinical research, the PSQI has high reliability and validity in measuring sleep quality.[37] The PSQI has also been proposed as the primary method to measure sleep quality by expert consensus recommendations.[38]

    In summary, the PSQI is a practical measure of sleep quality. Numerous independent studies have repeatedly validated the reliability and validity. Thus, the PSQI is one of the most widely used subjective measures of sleep quality — and rightly so.

    What are some of the main medical treatments for insomnia?

    Medication treatments for insomnia are indicated for improving sleep onset, sleep maintenance, or both. Examples of medications with evidence of benefit for insomnia include orexin receptor antagonists (suvorexant), nonbenzodiazepine hypnotics (eszopiclone Lunesta, zolpidem Ambien, zaleplon Sonata), certain benzodiazepines (triazolam, temazepam), melatonin agonists (ramelteon Rozerem), and certain antidepressants (doxepin Silenor). Although medications such as trazodone, tiagabine, and diphenhydramine are commonly used, experts do not recommend them for chronic insomnia due to potential harms and inadequate evidence of benefit.[4]

    Have any supplements been studied for insomnia?

    Supplements studied for insomnia include melatonin, valerian root, kava-kava, chamomile, lavender, and many others. These supplements have sedating effects and can increase relaxation and induce sleep in some people with short-term insomnia.[3] There is much less research on supplements for chronic insomnia.[4]

    Is there any evidence regarding melatonin toxicity, tolerance, and addiction?

    Overall, melatonin supplementation is relatively safe. First, melatonin toxicity is very low. Studies testing up to 240 mg[9] and 500 mg[10] taken orally do not report any toxic effects. Second, tolerance does not seem to be an issue. A study examining the continued administration of melatonin over 6–12 months did not find any evidence of tolerance.[11] Third, there is currently no evidence to support addiction or withdrawal symptoms. However, doses higher than 2 mg have not been sufficiently studied over the long term. Lastly, if you’re worried about the potential testosterone-lowering effect of melatonin, rest assured, there is currently no conclusive evidence to support this claim.

    How could diet affect insomnia?

    A common therapeutic approach for alleviating insomnia is maintaining sleep hygiene, a part of which involves diet. Sleep hygiene techniques include not eating too much at night and not eating too late into the night. It also includes avoiding or limiting the intake of alcohol, caffeine, and caffeine-containing foods and drinks (e.g., coffee, tea, and chocolate), especially when it is close to bedtime. Following a healthy, nutrient-rich diet (e.g., high in fruits and vegetables, low in refined sugar) is also considered a part of maintaining good sleep hygiene.[3][2][5]

    How exactly might caffeine mess up my circadian rhythm?

    The circadian clock in humans is controlled primarily by the suprachiasmatic nucleus (SCN) within the brain. The SCN is a group of cells that sit by the optic nerve and respond to light and other stimuli that come in from the eye. Hypothetically, caffeine could affect the SCN (and other tissues throughout the body) in various ways, depicted below.

    Possible ways caffeine could affect circadian rhythm

    image

    One way is through increasing a cell’s levels of cyclic AMP (cAMP), which is often created inside a cell in response to a signal. This occurs for two reasons. First, caffeine blocks adenosine receptors that normally reduce cAMP levels. Second, caffeine binds phosphodiesterase enzymes that act to degrade cAMP.[19] When these enzymes are blocked, cAMP levels are raised.

    It's also been shown that circadian rhythms within the SCN are regulated in part by the release of calcium ions during the stimulation of ryanodine receptors,[20] which caffeine also binds.[21]

    How does alcohol affect my sleep?

    At first, alcohol can help you fall asleep, but this effect fades off after a few days if you keep drinking close to bedtime.[33] And right from the start, it will impair the quality of your sleep.[34][35] Ironically, alcohol-use disorders have even been linked to insomnia, though their being cause or consequence is uncertain.[33]

    In short, don’t use alcohol as a sleep aid — it might help you relax, but it will impair the quality of your sleep. You may find it beneficial to avoid alcohol after dinner.

    Are there any other treatments for insomnia?

    For short-term insomnia, sleep hygiene techniques which involve adjusting lifestyle factors (e.g., diet, exercise) and environmental factors (e.g., light, noise, temperature) is commonly recommended, however, sleep hygiene is not recommended as a solo treatment for chronic insomnia. For chronic insomnia, cognitive behavioral therapy (CBT) has good evidence of benefit, especially when used in combination with other therapies. Sleep hygiene and CBT are usually recommended in combination with other behavioral treatments such as sleep restriction, relaxation therapy, and stimulus control.[6]

    What should you avoid doing before bed?

    If you ask people what they’d like to do before bed, you might hear answers such as meditate or read a book. But in reality, texting, playing games, or working is becoming more prevalent by the year, to the probable detriment of sleep quality.[27]

    Aside from fiendishly typing and checking social media, are there any other activities you should avoid in order to get a sound night’s sleep?

    Eating right before bed is often targeted as a sleep killer. But the evidence is more nuanced; in some people, consuming small amounts of food, such as a glass of milk or a small snack, can benefit sleep.[28] Nighttime exercise is another frowned-upon activity, yet a recent trial[29] and survey[30] evidence has shown a potential benefit on sleep.

    As it stands, excess light exposure is more likely to hurt your sleep than your choice of pre-bed activities. The bright lights of a gym will have this effect, as will using a tablet or any other blue light-emitting device.[31][32]

    What causes insomnia?

    Common causes of insomnia include work stress, relationship issues, or traumatic events. Often times, insomnia occurs in response to certain medical conditions, medicines, and other sleep disorders (e.g., obstructive sleep apnea). Caffeine, tobacco, alcohol, and other substances can also trigger insomnia. However, in some cases, insomnia is considered to be a primary problem because it does not have an identifiable cause, although risk factors include long-lasting emotional upset, stress, travel, and shift work.[1]

    How does sun exposure influence sleep?

    Sunlight exposure does not just result in vitamin D production in our skin. It can also directly influence sleep quality through its effects on our circadian rhythms.[22] Increased exposure to sunlight in elderly nursing home residents can improve sleep quality scores.[23] Similarly, workers in windowless offices suffered from poorer sleep quality than those working by windows.[24] For workers in Antarctica in the winter,[25] the benefits of light can be produced using bright sun lamps, which make up for the negative effects of under-exposure of sunlight on sleep.[26] So, it seems that increased sun exposure could benefit sleep quality both through improved circadian rhythms and also increased vitamin D levels. Therefore, sun exposure is a confounding factor when studying the relationship between vitamin D levels and sleep.

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    Examine Database References

    1. Sleep Duration - Jinrong Lian, Yi Zhong, Hang Li, Siyuan Yang, Jiahe Wang, Xiang Li, Xinmin Zhou, Gang ChenEffects of saffron supplementation on improving sleep quality: a meta-analysis of randomized controlled trialsSleep Med.(2022 Apr)
    2. Sleep Duration - Langade D, Kanchi S, Salve J, Debnath K, Ambegaokar DEfficacy and Safety of Ashwagandha (Withania somnifera) Root Extract in Insomnia and Anxiety: A Double-blind, Randomized, Placebo-controlled StudyCureus.(2019 Sep 28)
    3. Sleep Duration - Jasmine Mah, Tyler PitreOral magnesium supplementation for insomnia in older adults: a Systematic Review & Meta-AnalysisBMC Complement Med Ther.(2021 Apr 17)
    4. Sleep Duration - Behnood Abbasi, Masud Kimiagar, Khosro Sadeghniiat, Minoo M Shirazi, Mehdi Hedayati, Bahram RashidkhaniThe effect of magnesium supplementation on primary insomnia in elderly: A double-blind placebo-controlled clinical trialJ Res Med Sci.(2012 Dec)
    5. Sleep Duration - Hornyak M, Voderholzer U, Hohagen F, Berger M, Riemann DMagnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study.Sleep.(1998-Aug-01)
    6. Sleep Duration - Lee J, Jung HY, Lee SI, Choi JH, Kim SGEffects of Passiflora incarnata Linnaeus on polysomnographic sleep parameters in subjects with insomnia disorder: a double-blind randomized placebo-controlled study.Int Clin Psychopharmacol.(2020-Jan)
    7. Sleep Quality - Lemoine P, Nir T, Laudon M, Zisapel NProlonged-release melatonin improves sleep quality and morning alertness in insomnia patients aged 55 years and older and has no withdrawal effectsJ Sleep Res.(2007 Dec)
    8. Sleep Quality - Luthringer R, Muzet M, Zisapel N, Staner LThe effect of prolonged-release melatonin on sleep measures and psychomotor performance in elderly patients with insomniaInt Clin Psychopharmacol.(2009 Sep)
    9. Insomnia Signs and Symptoms - van Geijlswijk IM, Mol RH, Egberts TC, Smits MGEvaluation of sleep, puberty and mental health in children with long-term melatonin treatment for chronic idiopathic childhood sleep onset insomniaPsychopharmacology (Berl).(2011 Jul)
    10. Sleep Quality - Inn-Sook Lee, Gyung-Joo Lee[Effects of lavender aromatherapy on insomnia and depression in women college students]Taehan Kanho Hakhoe Chi.(2006 Feb)
    11. Sleep Quality - George T Lewith, Anthony Dean Godfrey, Philip PrescottA single-blinded, randomized pilot study evaluating the aroma of Lavandula augustifolia as a treatment for mild insomniaJ Altern Complement Med.(2005 Aug)
    12. Sleep Quality - Li-Wei Chien, Su Li Cheng, and Chi Feng LiuThe Effect of Lavender Aromatherapy on Autonomic Nervous System in Midlife Women with InsomniaEvidence-Based Complementary and Alternative Medicine.()
    13. Sleep Quality - Hemmeter U, Annen B, Bischof R, Brüderlin U, Hatzinger M, Rose U, Holsboer-Trachsler EPolysomnographic effects of adjuvant ginkgo biloba therapy in patients with major depression medicated with trimipraminePharmacopsychiatry.(2001 Mar)
    14. Sleep Quality - D E Shumov, I A Yakovenko, N N Alipov, Z V Bakaeva, E B Yakunina, A N Minyuk, A V Vinokurov, V B Dorokhov[The effect of music containing binaural beats on daytime fall-asleep dynamics]Zh Nevrol Psikhiatr Im S S Korsakova.(2020)
    15. Sleep Quality - David J Rog, Turo J Nurmikko, Tim Friede, Carolyn A YoungRandomized, controlled trial of cannabis-based medicine in central pain in multiple sclerosisNeurology.(2005 Sep 27)
    16. Sleep Quality - Mark A Ware, Tongtong Wang, Stan Shapiro, Ann Robinson, Thierry Ducruet, Thao Huynh, Ann Gamsa, Gary J Bennett, Jean-Paul ColletSmoked cannabis for chronic neuropathic pain: a randomized controlled trialCMAJ.(2010 Oct 5)
    17. Sleep Quality - Fernández-San-Martín MI, Masa-Font R, Palacios-Soler L, Sancho-Gómez P, Calbó-Caldentey C, Flores-Mateo GEffectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trialsSleep Med.(2010 Jun)
    18. Sleep Quality - Leathwood PD, Chauffard FAqueous extract of valerian reduces latency to fall asleep in manPlanta Med.(1985 Apr)
    19. Sleep Quality - Shinjyo N, Waddell G, Green JValerian Root in Treating Sleep Problems and Associated Disorders-A Systematic Review and Meta-Analysis.J Evid Based Integr Med.(2020)
    20. Sleep Quality - Bent S, Padula A, Moore D, Patterson M, Mehling WValerian for sleep: a systematic review and meta-analysis.Am J Med.(2006-Dec)
    21. Insomnia Signs and Symptoms - Taavoni S, Ekbatani N, Kashaniyan M, Haghani HEffect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trialMenopause.(2011 Sep)