Mark Eric Dyken, MD
Department of Neurology
University of Iowa Hospitals and Clinics

First Published: September 2000
Last Revised: December 2000
Peer Review Status: Internally Peer Reviewed

What are some common treatments/remedies for sleeplessness?

The big problem is suggested by the question... there is an oversimplification of sleep disorders by physicians, health care professionals and the public, in general. In the international classification of sleep disorders, there are well over 80 specific causes of sleeplessness. As such, simplistically speaking, there are well over more than 80 specific ways to treat sleeplessness that is entirely dependent on the diagnosis or the problem causing that sleeplessness. For example, obstructive sleep apnea, where people stop breathing in sleep. If I used one of the common sedatives used for difficulty with sleep related to anxiety, a medicine that is a breathing suppressant, I could actually kill the patient with the wrong medication and by oversimplifying the problem.

I fall asleep quickly, but frequently wake up aafter an hour or two, and then have difficulty falling asleep again. Is there anything I can do?

Again, alluding to the answer from the previous question, a full history, sleep history and waking history, an examination must be performed before a simplistic answer can be given as the potential number of causes disrupting sleep are many. Nevertheless, you complain about sleep maintenance insomnia, which can be due to multiple causes. I would initially start out by having you keep a very strict sleep diary and waking diary documenting your regular bedtimes, awakening times, total sleep time at night, the number of times you take naps and their duration, and how you feel throughout a 24-hour period in regard to being sleepy and rested. In many ways, a good sleep diary can often allow the patient to "heal themselves" by discovering, by simple history taking, any relatively obvious components that may disrupt their sleep/wake schedule. After a patient has kept such a diary, if the problem persists despite recommendations that might include improving their overall sleep hygiene, that is keeping regular bedtime, awakening times, sleeping at least 7 to 9 hours per night on a regular basis, avoiding undue sleep deprivation and possibly daytime naps, then a visit to the sleep clinic with a sleep expert who takes a full history, sleep and waking history and performs a full physical examination can often lead to specific recommendations as specific etiologies, or causes of the problem may be uncovered. After such a time, if there is still a question before therapy can be instituted, consideration might be given to performing an overnight sleep study, a polysomnogram with a follow-up multiple sleep latency tests, a way of determining how sleepy a person is, might be considered to find the specific problem and hopefully specific treatment. In answer to your question, yes, potentially all sleep disorders can be addressed with variable success and therapies but a common sense routine approach to all sleep disorders must initially begin before a knee jerk response for therapy can be instituted. Simplistically, there is no "cure-all" for all sleep disorders.

My husband snores very loudly, has had his uvula removed to no avail. He wakes himself up snoring every 1-5 minutes then shakes his feet, as if rocking himself back to sleep, then the process begins again. Any answers?

The suggestion of persistent problems with arousal in sleep associated with loud snoring in a person who has had his uvula removed is that the person has underlying obstructive sleep apnea. Or, the upper airway resistance syndrome. I, if he were my relative, would have an overnight sleep study performed, with a daytime sleepiness study to follow to determine: 1. If he does stop breathing at night or, how severe the snoring is and how often it disrupts his sleep. 2. How low his oxygen level drops should he stop breathing and the heart's response to that low oxygen. 3. How sleepy his disrupted sleep from either apnea, where he stops breathing, or loud snoring makes him. If he has significant problems with breathing, I would then recommend the use of continuous positive airway pressure therapy, simplistically known as CPAP with the therapy to be initiated in the sleep laboratory setting to assure the resolution of all major events. Surgery, as suggested, is another viable option in regard to the therapy for sleep apnea and upper airway resistance syndrome. But, like all therapies, it does not always work.

I "manage" my insomnia by taking a Benadryl every evening...is this ok for long-term use?

In general, I like to avoid the chronic use of any medications if at all possible as all medicines can have potential side effects and, in some instances, as I have directly stated earlier, can mask some primary underlying sleep disorders. Nevertheless, there are people who have insomnia secondary to anxiety, depression, and multiple stressors who successfully have those primary problems addressed with chronic medications with resultant improvement in their underlying sleep complaints. Benadryl, though, is not a specific medication for some of these problems and, as such, other medicines might be more preferable in this specific case.

I always have trouble falling asleep on Sunday evenings after the weekend and it affects Monday and then Tuesday. Could this be insomnia and what can I do?

Insomnia, by definition, is a very general term with difficulty initiating and/or maintaining sleep or the subjective impression that an individual has poor quality sleep. So, in answer to the first portion of the question, yes, this is a transient period of insomnia. As I suggested to a previous question, a sleep diary is often very helpful in allowing the patient to "know themselves." My hypothesis, again oversimplified without a full history and physical being taken, is that the weekend is your time off, is your escape, and, in many regards, may be like your Christmas evening that a child often encounters with excitation and relative pleasure. It is possible Sunday evening psychologically you are starting to address the long workweek and Monday morning with relative dread. Again, oversimplifying this question and playing with this potential hypothesis. Many of our sleep experts can institute psychodynamic therapies which include progressive relaxation therapies, stimulus control therapies, behavior modifications, cognitive therapies, self-hypnosis and even recommend things as simple as a warm glass of milk before going to sleep if this is something that is psychologically pleasing to the individual and agreeable to their digestive system to improve sleep in such a situation. I will repeat a full sleep diary and history and physical is the basic fundamental starting point from which all sleep experts frequently begin. So, I don't want to oversimplify your situation or its therapy but at least give you a general idea of what sleep experts often recommend.

What types of meds are used most commonly and can it be a safe option for those suffering from sleep disorders?

There are many medications. I think the suggestion is to give medications for general insomnias that include Zolpidem, which is also known as Ambien, some of the short-acting and long-acting benzodiazepines, and Sonata. Many of these medicines have been shown to be relatively safe when taken for less than a three-week period to help break the cycle of Psychophysiologic, that is conditioned insomnia where a person has essentially developed a tendency to expect having a bad night of sleep in their normal sleeping environment due to a variety of potential causes and they simply need to break the cycle. Conditioned insomnia can be the result of multiple causes. In an attempt to simplify this problem, I will refer you to Pavlov's dog, with the steak and the bell. If you take a dog and present it with a big steak, hundreds, maybe thousands of times and condition that presentation with the sound of a bell, hundreds, maybe thousands of times, eventually the dog will slobber and become hungry if only the bell is rung. If you have a life trauma, for example, the loss of a loved one, that psychological stress can produce a short-term insomnia. If that stressor and the poor sleep is not adequately addressed in some individuals, after a while, the person will associate the bedtime going to sleep with the trauma long enough that they may continue to have insomnia long after their loved one has passed away.

I am 7 weeks post-op for spinal fusion at L4/L5 & L5/S1. While I have always had sleep problems, they seem to be more pronounced now. At first I thought that the surgical pain (where the scar tissue was forming) was keeping me awake. I am not sure that that is the case. I have become more aware of my need to sleep with a pillow either under or between my knees. I find that my legs are bothersome, not really sharp pain, but annoying. I have tried Elavil in various dosages with varying degrees of success, but am concerned about the addiction. Any thoughts?

The question addresses many of the previously stated concerns I have when addressing a sleep problem as you suggest sleep from many causes including the pain from surgery, normal preferred sleeping positions, possibly the stress of surgery and medical problems which could all contribute to a new condition or Psychophysiologic insomnia problem. But, to oversimplify, and to address one of your specific complaints, there is a relatively common sleep problem called "restless legs syndrome" often associated with periodic limb movements in sleep, better known to many as nocturnal myoclonus which can be made worse in the postoperative period. Tricyclic antidepressants that you have taken are very good general pain medicines but tend to exacerbate restless legs syndrome and periodic limb movements in sleep. I would discuss this issue with your doctor and, after taking a sleep history and looking at your physical exam, consider the use of medications specific for restless legs syndrome and periodic limb movements in sleep. These include therapies as simple as iron supplements, levodopa, codeine, some of the benzodiazepines and some of the new anticonvulsant seizure medications. It should be noted that these drugs are given as they improve the discomfort but do not imply that you have underlying depression, seizures, or Parkinson's disease despite the fact that these medicines can also be given for those problems. That is in some cases.

Is it safe to take Diphenhydramine on a long-term basis for insomnia?

Over-the-counter medications have been used by many people but can have potential side effects and may mask underlying primary sleep disorders. Nevertheless, if you have been doing well with this medication without significant side effects, then it appears to be an individual issue and suddenly discontinuing that medication that you have may have become psychologically and possibly physiologically dependent upon might result in a worsening of your sleep disorder. As such, I would not cold turkey this medicine, but would encourage you, at some time, to consider seeing a sleep expert for a full evaluation and possibly safer, more effective long-term therapy.

Does one go to an ENT for diag. or sleep center?

At the University of Iowa, the ENT doctor, that is otolaryngologist, is part of the sleep disorder center medical team. You have alluded to the fact that sleep disorder medicine and the therapies for a multitude of sleep disorders is in its infancy. At most hospitals, a team of doctors with interdisciplinary expertise is generally not the norm. And, in many cases, the otolaryngologist, the ENT doctor, is the primary sleep expert, especially in regard to sleep-related breathing disorders such as obstructive sleep apnea, the upper airway resistance disorder, and loud snoring.

I am to stay away from non-steroidal anti-inflammitories. Instead of Motrin, my surgeon wants me to take Tylenol. Will I have any conflict with the meds that you listed for "restless leg syndrome"?

In general, Tylenol is safe to combine with the medications listed. But the potential problems you have with nonsteroidal anti-inflammatories may in and of themselves affect your candidacy for using some of the other previously mentioned drugs.

How would I find a good sleep center?

Most accredited sleep centers under the American Academy of Sleep Medicine can provide you, from their roster, excellent accredited centers, their telephone, addresses and fax numbers almost anywhere throughout the United States. Our laboratory/sleep center is accredited and if you can find no other accredited centers, call us and we can direct you to someone in your area.