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Insomnia - Treating insomnia

NHS Choices Medical Reference

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The first step in treating insomnia is to find out whether the problem is being caused by an underlying medical condition.

If it is, once the condition has been treated your insomnia may disappear without the need for further medical help.

Your GP should advise you on what you can do at home to help you sleep. This is often referred to as good sleep hygiene, and includes:

  • establishing fixed times for going to bed and waking up (avoid sleeping in after a poor night's sleep)
  • trying to relax before going to bed
  • maintaining a comfortable sleeping environment (not too hot, cold, noisy or bright)
  • avoiding napping during the day
  • avoiding caffeine, nicotine and alcohol late at night 
  • avoiding exercise within four hours of bedtime (although exercise in the middle of the day is beneficial)
  • avoiding eating a heavy meal late at night
  • avoiding watching or checking the clock throughout the night
  • using the bedroom mainly for sleep and sex if possible

Read more about simple methods that may help prevent insomnia.

If you have long-term insomnia (lasting more than four weeks):

  • your GP will advise you about good sleep hygiene
  • your GP may recommend cognitive and behavioural treatments
  • you may be prescribed a short course of sleeping tablets for immediate relief or to manage a particularly bad period of insomnia (although they aren't recommended for long-term use) 

Cognitive and behavioural treatments

Cognitive behavioural therapy (CBT) aims to change unhelpful thoughts and behaviours that may be contributing to your insomnia. CBT is usually recommended if you've had sleep problems for more than four weeks. It includes:

  • stimulus-control therapy, which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern
  • sleep restriction therapy - you limit the amount of time spent in bed to the actual amount of time spent asleep, creating mild sleep deprivation; sleep time is then increased as your sleeping improves
  • relaxation training - this aims to reduce tension or minimise intrusive thoughts that may be interfering with sleep
  • paradoxical intention - you try to stay awake and avoid any intention of falling asleep; it's only used if you have trouble getting to sleep, but not maintaining sleep
  • biofeedback - sensors connected to a machine are placed on your body to measure your body's responses, such as muscle tension and heart rate; the machine produces pictures or sounds to help you control your breathing and body responses

Sometimes, CBT is carried out by a specially trained GP. Alternatively, you may be referred to a clinical psychologist.

Sleeping tablets

Sleeping tablets (hypnotics) are medications that encourage sleep. They may be considered:

  • if your symptoms are particularly severe
  • to help ease short-term insomnia
  • if the non-drug treatments that are mentioned above fail to have an effect

However, doctors are usually reluctant to prescribe sleeping tablets as they relieve symptoms but don't treat the cause of your insomnia. If you have long-term insomnia, sleeping tablets are unlikely to help. Your doctor may consider referring you to a clinical psychologist to discuss other approaches to treatment.

Read more about why sleep medication only offers short-term relief.

You should be given the smallest effective dose possible for the shortest length of time necessary (for no longer than a week). In some cases, you may be advised to only take the medication two or three nights a week, rather than every night.

Sleeping tablets can cause the following side effects:

  • a feeling that you're hungover
  • drowsiness during the day

It's best to take sleeping tablets at night, before you go to bed. In some people, particularly older people, the hangover effects may last into the next day, so be cautious if you're likely to be driving the next day.

It's very easy to become dependent on sleeping tablets, even after a short-term course. 

If you're regularly taking sleeping tablets every night, consider reducing or stopping them. Speak to your doctor for advice.

Short-acting benzodiazepines or the newer 'Z medicines' (see below) are the preferred medicines for insomnia and are only available on prescription.

Benzodiazepines

Benzodiazepines are tranquillisers that are designed to reduce anxiety and promote calmness, relaxation and sleep.

These medicines should only be considered if your insomnia is severe or causing you extreme distress. All benzodiazepines make you feel sleepy and can lead to a dependency. If they're needed to treat insomnia, only the short-acting benzodiazepines (with short-lasting effects) should be prescribed, such as:

Z medicines

Z medicines are a newer type of sleeping tablet that work in a similar way to benzodiazepines. They're also short-acting medicines and include:

There's little difference between the benzodiazepines and Z medicines. If one doesn't work, then swapping to another is unlikely to have a different effect.

For more information, see the NICE guidance about the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia.

Melatonin (Circadin)

Medicines that contain melatonin have been shown to be effective in relieving insomnia for up to 26 weeks in elderly people. Melatonin is a naturally occurring hormone that helps regulate the sleep cycle (known as the circadian rhythm).

At present, Circadin is the only medicine that contains melatonin. It's licensed to treat insomnia. Circadin is only available on prescription for people who are 55 years old or over.

Circadin is designed as a short-term treatment for insomnia and shouldn't be taken for more than three weeks. It's not recommended for people with a history of kidney disease or liver disease.

As yet, there's not enough evidence to say whether it's safe to take Circadin during pregnancy or while breastfeeding, so its use isn't recommended under these circumstances.

Side effects of Circadin are uncommon but include:

If you find these side effects troublesome, stop taking Circadin and contact your GP.

Medical Review: September 11, 2011
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