Insomnia is not just a difficulty in falling asleep or staying asleep. It also means that you do not wake up feeling refreshed and do not feel alert during the next day.

No one very sure what sleep is for but it must be important. A human deprived of air, water, sleep or food, will die in a few minutes with no air, water after a few days, sleep after a week or so (very soon after water) and food after many weeks. Sleep must be vital to allow the body to recover and repair itself for recuperation and restoration, and we know that animals sleep and dream as well. If sleep is not absolutely vital, it is the biggest mistake evolution ever made!

There are four main stages of sleep:

• Stage 1 drifting off

• Stage 2 50% total sleep

• Stages 3 and 4 the most important parts e.g. memory, learning, forgetting, and growth. Has high need in children and drops with time. The older you get, the less phase 4 you get and the less satisfying, restorative and refreshing it becomes.

There are three main types of insomnia:

• Transient - lasts less than a week, and is often caused by depression, anxiety and stress

• Intermittent - poor sleep for a few days happening over several weeks 

• Chronic or primary insomnia - lasts for longer than a month. It can be caused by another condition (e.g. heart or kidney disease, sleep apnoea/apnea) or it can be a disorder of its own

^{Updated 9.11}

• Hide this answer
• Sources for this information

Insomnia is a problem with either dropping off to sleep or in staying asleep. It is very often a symptom of other illnesses rather than an “illness” in its own right. It can be caused by many things such as:

• stress
• mental health problems e.g. depression or anxiety
• emotional problems
• conflict
• physical illness (e.g. pain)
• medicines (prescribed, legal or illicit).

It can occur every now and again (transient) or be chronic (long-term, every night). It can be difficulties getting asleep, frequent waking or early morning waking.

Sleep should be "restorative". For instance, in Germany insomnia is called "non-restorative sleep". The important thing is to have the right sleep length for you. This might vary from 4 to 10 hours. Einstein used to sleep 10 hours a night. The important thing is how alert you feel during the day, and how awake you feel. If you don't sleep much but feel refreshed and feel alert for most of the day, then you are probably having enough sleep.

By the way, many studies have shown that if you don't sleep enough (for you) then you will feel more hungry the next day, especially from 7pm to 7am, and especially for "comfort foods" with a high sugar or calorie content. So, if you sleep enough, you will feel less hungry and find it easier not to eat all the wrong foods or stick to a diet.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Because everyone is unique, everyone's symptoms are different. So, it's not always clear what the right diagnosis is. Here is a list of some causes for insomnia. This is not meant to be a textbook list, just some ideas. Some of these can be very rare indeed. Unless there are neurological problems or brain illness, then insomnia is nearly always caused by something else, which needs treating.

• Substance misuse e.g. alcohol dependence, caffeine, nicotine, amphetamines, other recreational drugs

• ADHD (Attention Deficit Hyperactivity Disorder) can be the cause of long-term insomnia

• Mood disorders e.g. depression, bipolar mania or hypomania, anxiety or Generalised Anxiety Disorder, Panic disorder, PTSD (Post-Traumatic Stress Disorder), psychosis, Seasonal Affective Disorder

• Stress (personal, work, finance, education, medical)

• Noise at night or sleep time

• Bereavement

• Breathing problems (asthma, sleep apnea) - around half of all people with insomnia have sleep apnea, where the person snores and wakes a lot, and stops breathing for up to 10 seconds many times a night. This needs treating before anything else is done.  

• Medical problems e.g. heart (angina, heart failure), brain illnesses (Alzheimer's disease, Parkinson's disease), thyroid problems, pain (e.g. arthritis), irritable bowel syndrome, bladder problems (incontinence or prostate problems), restless legs, iron deficiency or anaemia   

^{Updated 9.12}

• Hide this answer
• Sources for this information

Basically, anyone can get insomnia, and indeed nearly all of us do at some time in our lives. However, there are some "risk factors" that make it more likely that someone will get insomnia. This is not a complete list but some of the main ones include:

• Having a mental health problem e.g. bipolar mood disorder, Attention Deficit Hyperactivity Disorder (ADHD), bipolar depression, anxiety, Post-Traumatic Stress Disorder (PTSD), Obsessive Compulsive Disorder (OCD), schizophrenia

• Non-prescribed drugs - such as stimulants, nocotine, caffeine, cocaine, ephedrine, amphetamines, 

• Prescribed medicine-induced e.g. some antidepressants, lamotrigine, beta-blockers, calcium channel blockers, hormones, stimulants (e.g. methylphenidate), asthma treatments (e.g. salbutamol, salmeterol, theophylline), modafinil, some antibiotics, some antiinflammaotries  

• Physical health problems ee.g. heart disease, breathing problems, Alzheimer's, low thyroid, bowel problems, incontinence  

• Hormone shifts especially estrogen e.g. being premenstrual, menopause

• Stress and life events e.g. fear, stress, anxiety, tension, work or financial problems, poor sex life, noise 

• Disturbed Circadian rhythm e.g. jet lag, shift work

• Brain problems e.g. tumours, brain injury

• Pain e.g. rheumatoid arthritis, high thyroid

• Stopping hypnotics - which can cause "rebound insomnia"

• Parasomnia e.g. nightmares, sleep-walking

• Infections e.g. gastrointestinal parasites

• Age - sleep gets worse as you get older unfortunately

• Breathing problems e.g. sleep apnea (see previous question)  

• Restless legs

• Poor sleep hygiene 

• Being female - insomnia is more common in women than in men

• History of light sleeping

Although there are many different types of insomnia, the problem is getting to sleep or waking up too early, or not a good sleep. We know that too little GABA (the brain's natural calming messenger) or too much glutamate (the brain's natural exciting messenger) will cause insomnia. Many medicines for insomnia boost GABA.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Our aim is to try to help people who are taking medication (or should be) get the right medicine, dose and take it regularly for as long as is right. Any medicines should usually be part of the overall treatment, although some people are quite happy just to stick with drugs or talking treatments. If your medicines are right, then everything else can fall into place. If the medicines are wrong, then they may make the symptoms worse and self-help will not be as useful.

The list here includes most of the main options but does not say what works and doesn’t. Many may be used in combination. Most herbal and alternative therapies have not really been tested in the same rigorous way that medicines have. Obviously, any causes should be tackled first before the use of hypnotic or sleeping tablets or capsules. Getting "sleep hygiene" right is also vital.

Self-help

Sleep hygiene is the way to give you the best chance of getting to sleep naturally:

• Avoid too much caffeine (tea, coffee, colas), alcohol or nicotine, especially in the couple of hours before going to bed. A hot milky (decaffeinated of course!) drink at bedtime may help
• Do not stay in bed for a long time if you are not asleep - get up for a short while and then go back to bed again
• Avoid daytime naps or long periods of sitting or lying around
• A warm bath or exercise a few hours before bedtime may help sleep
• Avoid strenuous exercise or mental activity near bedtime
• Make sure that the bed and bedroom are comfortable.
• Avoid excess noise and temperature (ear-plugs may help if there is much noise, or leaving a radio on soft music)
• Get up at the same time every morning, regardless of how long you slept (not easy but this makes sure that you are ready for sleep the next night).
• Carbohydrate (eg. pasta, etc) helps sleep, but not eating a big meal within about two hours of going to bed. Sugar may stop you sleeping, as may some vitamin supplements.

As well sleep hygiene, the following may be useful:

• Relaxation tapes and therapies and other self-helps may be useful
• Eating healthily and taking exercise  (“exercise to energise”) or being active can help promote regular sleep patterns
• Getting help for any problems that may be making it worse e.g. anxiety, low mood etc

Help from others

• Stimulus control therapy, relaxation therapy, sleep restriction therapy, biofeedback
• CBT (Cognitive Behavioural Therapy)
• Diagnosing and treating any underlying causes
• Alternative therapies such as aromatherapy, hypnotherapy or hypnotherapy (which has been shown to help, see the Hypnotherapy Directory to find one), homeopathy (click for a review of the 25 studies in mental health by Davidson 2011) (treating like with like) can be used with (but not instead of) conventional treatments. Auricular acupuncture (AA) can help and is used extensively in many countries for insomnia. The evidence for these treatments is not very robust. All of these can be used in conjunction with other therapies. If they work then that is fine and we wouldn’t knock them. They can be helpful for allowing you to relax at night. Click here for a balanced review of complementary and alternative therapies from the Royal College of Psychiatrists (e.g. Ginkgo, Sage, vitamins, other herbals etc, and some useful links).

Medication

• Sleeping tablets or capsules (more correctly known as “hypnotics”).

^{Updated 4.13}

• Hide this answer
• Sources for this information

If you are prescribed a medicine, then there may be many reasons why that one has been chosen. These might include:

• side effects (which ones are important to you)
• local policies or agreements (such as what your GP surgery uses or agreements in your area)
• national policies (e.g. NICE, SIGN - see last question)
• familiarity (it may be better for prescribers to use medicines they are familiar with)
• relative costs for similar medicines (if two medicines are very similar, why waste money on the more expensive one?)
• personal preference (either yours or your prescriber)
• how bad your symptoms are
• any medicine you might have done well with in the past (as it's more likely to work again) 

The main medicine treatment options are listed below. They are divided into "Main medicines" and "Others".

For convenience, the "Main medicines” are those medicines that are officially "approved" to treat the condition or symptoms (www.bnf.org/bnf/) and which are listed in the British National Formulary (BNF). To be listed in the BNF there needs to be good evidence that the medicine works and that the manufacturers have applied for a license (a long and costly exercise). "Others" are those medicines where there is some evidence that they help, but either not enough for a license or that no license has been applied for. These should usually only be used where other standard treatments have failed.

The choice of medicines can be based on your problem. If getting to sleep is the main problem, a short-acting sleeping tablet or capsule may be more helpful. If staying asleep is the problem, then a longer-acting sleeping tablet or capsule may be better. However, the longer-acting ones are more likely to cause some “hang-over” effect the next morning.

Main medicines

BNF Listed:

Benzodiazepines

• Flurazepam
• Loprazolam
• Lormetazepam
• Nitrazepam
• Temazepam
• There are many other benzodiazepines used across the world e.g. flunitrazepam

Z-hypnotics

• Zaleplon (Sonata® - very short-acting)
• Zolpidem (Stilnoct® - very short-acting)
• Zopiclone (Zimovane® - fairly short-acting)

Other hypnotics

• Antihistamines (such as promethazine or diphenhydramine)
• Barbiturates (severe cases only)
• Chloral hydrate (if you can stand the taste)
• Clomethiazole (chlormethiazole, Heminevrin®) - for older people only
• Melatonin (Circadin®) - now licensed in the UK as a 13 week course for people aged 55 or older, although it can help younger people too   

Others:

• Mirtazapine (an antidepressant with a strong effect on histamine that causes sedation)
• Antipsychotics (sedative ones, such as quetiapine)
• Trazodone
• Tricyclics such as amitriptyline, doxepin, dosulepin or imipramine (often used as antidepressants), are sometimes used in low dose just for their sedative effect, although really low doses (e.g. 2-10mg at night) of some may have a good effect. 

In addition, we ought to make mention that many people "self-medicate" with drugs like alcohol, but this isn’t prescribable yet. And probably won't ever be either.  

There has been a study published in 2012 that says that the risks of dying or getting cancer over 2.5 years appear higher when the person is taking hypnotics, even less than 18 doses per year. This suggests to us that there must be some other explanations or the world’s early death rates ought to be much higher (Kripke 2012), so maybe the risk is from poor sleep rather than the sleeping tablets.

It should be added that some of these medicines may make you feel drowsy and perhaps more relaxed, and so may help you get to sleep. However, not all of them make that sleep more refreshing or restorative. In other words, you might sleep, but not as well.

By the way, make sure you swallow the dose with at least half a glass of water to make sure it reaches your stomach quickly. It won’t help you sleep if it’s stuck halfway down.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Download a handy summary chart (PDF format) comparing the main medicines for insomnia e.g. names, how they work, doses, how long they take to work, some side effects, how long to take and how to stop.

^{Updated 5.12}

• Hide this answer
• Sources for this information

You should think carefully about taking any chemical that affects the brain. So think carefully before your next cup of tea or coffee! Particularly if you want to go to sleep tonight.

Hypnotics (sleeping tablets) are a useful treatment in the short-term e.g. a few weeks, but can have problems if taken for many months. It is best to try to solve the problems causing the poor sleep first. The shorter-acting hypnotics (e.g. zolpidem, zaleplon) tend to have fewer "hangover" effects the next morning, which must be safer.

A study published in February 2012 suggested that people who take sleeping tablets even twice a month were 4-6 times more likely to die early than people who don't. Whilst this is from a well-respected sleep expert, we find the results rather hard to accept, because if true then there would be many fewer people alive in the UK than there are. To our mind, the problem is that there is a comparison made between people taking sleeping tablets and people who don't. Much better would be to compare people who do and people with insomnia who don't. We know that untreated insomnia can cause road accidents, depression, increased alcohol intake and work problems and injuries. So it's an unfair comparison. However, it is a warning that some such medicines might cause unexpected effects (http://www.telegraph.co.uk/science/science-video/9109678/Sleeping-pills-may-be-as-dangerous-as-smoking-cigarettes-says-lead-author-of-new-report.html).

For an appeal for everyone to have a sense of balance about medicines and talking therapies please click here for our take on it.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Many people can take hypnotics for a while just to get their sleep pattern established or just when they need them. It is possible that they may begin to lose their effect after a few months of regular use so it is a good idea not to take them regularly.

Melatonin is often taken as a "course". The aim with melatonin is to boost and re-set the brain's natural rhythm by getting meltonin released at the right time. It is usually best taken for between 3 and 13 weeks.

It is worth knowing that hypnotics tend to lose their effect the longer you take them. You might then need to take higher doses to get the same effect. Taking them "when required", only e.g. three times a week, alternate nights etc can help to preserve the effect. If you stop them, be aware that you might get some "rebound insomnia". This is where your sleep problem may get worse for a few days before settling down again.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

You should usually find out if a hypnotic is working within an hour or so of taking it. It is absolutely vital to combine a hypnotic with other strategies i.e. sleep hygiene.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

There are no easy answers to this and it is a very individual choice. Generally one medicine should always be the aim but combinations (often called “polypharmacy”) sometimes help. It is rarely of any use to combine drugs with similar ways of working. It is not usually necessary to have more than one medicine for insomnia.

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

If you want to read up a bit more on the best treatments, there are many guidelines that you can look at. Probably the most important of these for England and Wales are those produced by NICE (the National Institute for Health and Clinical Excellence). NICE is an independent body that is asked to produce advice about preventing and treating illnesses and promoting good health. Scotland and Northern Ireland have their own similar bodies.

Each set of NICE Guidelines is written by an independent and carefully chosen group of specialists and experts (including service users and carers). They carefully review the available evidence and base their guidelines on this.

There are two main types of NICE guidance:

• "Technology appraisal". These look at an "intervention" (i.e. a medicine, a surgical operation etc) and decide if they think the evidence is good enough to make this intervention a standard and/or if it is cost-effective compared to other treatments

• "Clinical guidelines", which look at a particular condition (e.g. hypertension, lung cancer, depression, Parkinson's disease, bipolar disorder etc) and give guidelines covering medicines, services, support etc.

The guidelines are well intentioned and give generally sound guidance (although these are sometimes controversial). They are, however, only "guidelines", so are not rigid instructions.

When NICE issues a guideline, it produces a full set, and all of these are available on the NICE website:

• Full guideline (very long and detailed, often several hundred pages, for anorak healthcare professionals only)

• Official guideline (usually 10-30 pages, the summary version for healthcare professionals)

• Quick reference guideline for healthcare professionals (usually only a couple of pages)

• User-friendly summary for service users, carers and the general public

These should then be reviewed, usually about 4-5 years or sooner if more information becomes available.

As a general rule, you should start with treatments recommended by NICE as these are the ones with most evidence that they work. However, if these do not help you, it may be useful to try other treatments.

• NICE (click here for the hypnotics guidelines, although the author of this page doesn't agree with some of the views in their guidance)

• Scottish Intercollegiate Guidelines Network (SIGN), although they haven't currently got any guidelines on insomnia or its teratment

• Northern Ireland

There are plenty of other guidelines and so-called "consensus statements" (where a group of experts and specialists pool their ideas, based on their own experiences as well as what the published papers say, rather than just what the published studies say). These will have been produced for healthcare professionals by such bodies as BAP (British Association for Psychopharmacology).

^{Reviewed 4.13}

• Hide this answer
• Sources for this information

Use the resources below to find out more information about insomnia. Please note that this is not an exhaustive list and we can take no responsibility for the content of these sites. We welcome your feedback on resources that you think should be listed here.

• How did you sleep? has lots of useful stuff. Last time we checked it out, you could download a Sleep Guide to improve your sleep, find out why sleep matters, and test your sleep in-depth with the Great British Sleep Survey.

• Mental Health Ireland has a great links page on this extensive site
• Your Mental Health Ireland, with a young person’s page as well

• The British Association for Psychopharmacology has a BAP public area, which has loads of interesting articles, some mentioning insomnia and sleeping problems.

• The Big White Wall is a 16+ safe, anonymous web-based service for people experiencing emotional or psychological distress provided entirely online. Professionally staffed 24/7 it offers a wide range of services for improving mental wellbeing including tests, peer support, individual and group therapies, articles, tips and creative self expression. Simply click on the link to learn more, or to join for £2.00 a week.

  ^{Updated 3.13}

• Hide this answer
• Sources for this information