Mark Eric Dyken, MD
Department of Neurology
University of Iowa Hospitals and Clinics
First Published: September 2000
Last Revised: December 2000
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
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
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
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
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
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.