Sleep Disorders

Updated 11 August 2014

Diagnosis and treatment of insomnia

The first steps to diagnosing and treating insomnia.


Diagnosing insomnia

To diagnose the cause of insomnia, your doctor will perform a complete physical exam and take a medical history, which will include your lifelong sleep patterns, previous experiences of insomnia and recent life stresses.

Be sure to tell your doctor about any prescription or non-prescription medications you might be taking, as well as stimulants such as coffee.

He or she may also want to interview your sleeping partner about your sleep patterns, as your partner may observe aspects of your behaviour during sleep of which you are unaware. Your doctor may also ask you and your partner to keep diaries of your sleep patterns for a few weeks.

Diagnostic tests
In most cases, the cause will become apparent through the medical history and physical examination.

If there is evidence of an additional sleep disorder, such as sleep apnoea, your doctor may recommend a sleep study, or "nocturnal polysomnography". These studies are usually done in a sleep laboratory in a medical centre, where you spend the night in a hospital-type room while specialised machines monitor your heart, lung, brain and muscle activity.

Treatment of insomnia

Transient and intermittent insomnias may resolve on their own if they are due to a temporary disruption in your sleep schedule.

However, if the insomnia is caused by a particularly stressful situation or pain from some physical condition; or if daily efficiency and quality of life are seriously impaired by sleeplessness, your doctor may prescribe short-acting sleeping pills.

Anyone taking sleeping pills should be closely supervised to evaluate the drug's effectiveness and side effects. Take the lowest dose necessary to relieve your symptoms.

Prescribed sleeping medications can be useful in some cases of insomnia and, when used properly, can be the quickest form of treatment. However, they should be considered as a temporary solution only.

After a few weeks, they may lose their effectiveness, making some people raise the dosage.

There is a risk of physical addiction to these medications and of injury from falls when getting up at night to use the bathroom (especially for older people.)

Over-the-counter medications often complicate insomnia. They may help you fall asleep, but sleep quality is usually poor. Long-term use often worsens insomnia and makes it more difficult to treat. Use these medications only if your doctor recommends them.

Never combine sleep-inducing drugs with even a small amount of alcohol, as this is a sedative which can compound their effects.

Behavioural therapy
Behavioural techniques can be as effective as sleeping pills and have no side effects. The goal is to help you "learn" healthy sleeping habits. Examples of behaviour therapy include:

  • Relaxation therapy aims to relax the mind and muscles by focusing on the repetition of a word, sound or muscular activity (tensing and releasing muscles while lying in bed), without actively excluding other thoughts or feelings. The aim is to relax passively by accepting each thought or emotion as it arises.
  • Sleep therapy involves allowing a few hours of sleep during the night and gradually increasing the time until you reach a normal night's sleep.
  • Reconditioning aims to alter how you associate your bed and bedtime with sleep. You avoid using the bed for anything but sleep and intimacy, go to bed only when sleepy, and leave the bedroom if you can't sleep. You also learn to avoid naps, and sleep at the same time each day.

Herbal Remedies

  • Melatonin: a hormone produced by the pineal gland. Small amounts may help regulate the sleep cycle in people with a deficiency. Despite its widespread use for insomnia, little is known about melatonin. However, many of the melatonin products available contain unknown substances, so it should be used with caution.
  • Camomile: a calming, relaxing tea.
  • Valerian: a herbal tranquilliser that helps relax muscles.

Always tell your doctor when you are using alternative therapies as they may interact with prescription drugs, and often have side effects of their own.

Home treatment and prevention

Many sleep problems can be overcome by simple, commonsense measures:

  • Cut down on late-night snacks and late-evening heavy dinners. Some experts recommend that you should not eat at least three hours before bedtime.
    Protein promotes alertness and carbohydrates calm and drowsiness, so eat a light, high-protein, low-carbohydrate lunch. This will decrease early afternoon drowsiness, and make an afternoon nap less tempting.
    Conversely, a high-carbohydrate, low-protein supper should help encourage sleepiness closer to bedtime.
  • Exercise - even moderate exercise helps control stress and releases natural stimulants, decreasing the need for external stimulants such as caffeine. An exercise routine should help regulate your sleep cycles and make you feel sleepier in the late evening.
    However, avoid exercising vigorously too close to bedtime.
  • Don't use your bedroom, even less your bed, as a place for activities other than sleep and intimacy. Get into bed when you are ready to sleep and leave it when you wake, to avoid sending your body conflicting cues about sleep and waking life.
    If you wake up in the middle of the night and can't fall asleep within half an hour, get up and rest or read in a comfortable chair until you become sleepy.
    Establish a bedtime ritual of cues for going to sleep. These could include having a bath or drinking a glass of warm milk (milk contains an amino acid that is converted into a sleep-enhancing compound in the brain).
    Many people feel relaxed after sex. Relaxation techniques (see above) may also be useful.
  • Cut down on daytime napping if it starts to affect your regular sleep patterns. Avoid napping within seven or eight hours of bedtime.
  • Avoid alcohol in the late evening.
  • If your insomnia persists, keep a diary of your sleep history. This may be helpful later in diagnosing an underlying cause.

Reviewed by Prof M. Simpson, MB., BS. (London ); MRCS, LRCP; MRCPsych, DPM


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Sleep disorders expert

Dr Alison Bentley is a general practitioner who has consulted in sleep medicine and sleep disorders, in both adults and children of all ages, for almost 30 years. She also researches and publishes on a number of sleep-related topics both in formal research journals and lay publications including as editor of Sleep Matters, an educational newsletter on sleep disorders for doctors.

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