Insomnia is difficulty getting to sleep or staying asleep for long enough to feel refreshed the next morning, even though you've had enough opportunity to sleep.
Most people experience problems sleeping at some point in their life. It's thought that a third of people in the UK have episodes of insomnia. It tends to be more common in women and more likely to occur with age.
It's difficult to define what normal sleep is because everyone is different. Your age, lifestyle, environment and diet all play a part in influencing the amount of sleep you need.
The most common symptoms of insomnia are:
difficulty falling asleep
waking up during the night
waking up early in the morning
feeling irritable and tired and finding it difficult to function during the day
What causes insomnia?
Stress and anxiety are common causes of insomnia, but it can also be caused by conditions such as depression, schizophrenia or asthma, some medications, and alcohol or drug misuse.
What to do
There is a range of things you can do to help you get to sleep, such as:
avoiding caffeine later in the day
avoiding heavy meals late at night
setting regular times to wake up
using thick curtains or blinds, an eye mask and earplugs to stop you being woken up by light and noise
This is often referred to as 'good sleep hygiene'.
Relaxation can also help. Try taking a warm bath an hour before you go to bed or listening to calming music.
When to see your GP
See your GP if you're finding it difficult to get to sleep or to stay asleep, and it's affecting your daily life.
Fatigue due to insomnia can affect your mood and create relationship problems with loved ones and work colleagues.
Your GP may ask you about your sleeping routines, your daily alcohol and caffeine consumption, and your general lifestyle habits, such as diet and exercise.
They will also check your medical history for any illness or medication that may be contributing to your insomnia.
Your GP may also suggest that you keep a sleep diary. This will help them and you to gain a better understanding of your sleep patterns. It can also help to decide which method of treatment to use.
You should keep a sleep diary for a minimum of two weeks, recording information such as:
the time you go bed
how long it takes you to get to sleep
the number of times you wake up in the night
what time it is when you wake up
episodes of daytime tiredness and naps
what time you eat meals, consume alcohol, take exercise and when you are stressed
The first step in treating insomnia is to identify and treat any underlying health condition, such as anxiety, that may be causing your sleep problems.
Your GP will probably discuss things you can do at home (see above) which may help to improve your sleep.
In some cases, cognitive behavioural therapy for insomnia (CBT-I) may be recommended. CBT-I is a type of talking therapy that can help you avoid the thoughts and behaviours affecting your sleep.
Sleeping tablets are a treatment of last resort and are often only used in the short-term with the smallest possible dose. Although they can sometimes relieve the symptoms of insomnia, they don't treat the cause. If you have long-term insomnia, it's unlikely that sleeping tablets will help.
Symptoms of insomnia
The symptoms of insomnia depend on the type of sleeping problem you have.
In the UK, up to a third of people are thought to experience insomnia at some point each year. Symptoms can include:
lying awake for long periods at night before falling asleep
waking up several times during the night
waking up early in the morning and not being able to get back to sleep
feeling tired and not refreshed by sleep
not being able to function properly during the day and finding it difficult to concentrate
A lack of sleep can also affect your mood and cause tiredness and fatigue during the day.
How much sleep do I need?
It's difficult to define what 'normal sleep' is because every individual is different. Many things influence the amount of sleep you need, including your age, lifestyle, diet and environment.
Most healthy adults sleep for about seven to nine hours a night. As you get older, it becomes more difficult to maintain that amount, even though you still need it.
When to visit your GP
You should consider speaking to your GP if a lack of sleep is affecting your daily life and you feel that it's causing a problem.
Fatigue caused by insomnia can affect your mood and create problems with personal relationships and in the workplace.
Causes of insomnia
Insomnia can be caused by many different things, includingstress, underlying health conditions, and alcohol or drug misuse.
The causes of insomnia are discussed in more detail below.
Some people develop insomnia in response to a stressful event, and it continues even when the stress has been resolved. This is because they have become used to associating the sleeping environment with being alert.
Worrying about things, such as work and health, is likely to keep you awake at night. Worrying about not being able to fall asleep can also stop you from actually falling asleep, creating a 'vicious circle'.
Underlying psychiatric problems can often affect a person's sleeping patterns. For example:
mental health conditions –such as depression or bipolar disorder
anxiety disorders – such as generalised anxiety, panic disorder orpost-traumatic stress disorder
psychotic disorders – such as schizophrenia
Insomnia can also be caused by underlying physical conditions including:
respiratory disease –such as chronic obstructive pulmonary disease or asthma
neurological disease –such as Alzheimer's disease orParkinson's disease
hormonal problems – such as an overactive thyroid
joint or muscle problems – such as arthritis
problems with the genital or urinary organs –such as urinary incontinence or an enlarged prostate
sleep disorders – such as restless legs syndrome, narcolepsy orsleep apnoea
Alcohol and drug misuse
Drinking too much alcohol and taking drugs can affect a person's sleeping pattern.
Stimulants, such as nicotine and drinking too much caffeine (contained in tea, coffee and energy drinks) can also affect your sleep.
Some prescribed treatments or medicines available over-the-counter can cause insomnia. These include:
medication for high blood pressure (hypertension), such as beta-blockers
hormone replacement therapy
non-steroidal anti-inflammatory drugs (NSAIDs)
stimulant drugs, such as methylphenidate, which is often used to treat attention deficit hyperactivity disorder (ADHD) or modafinil, which is used to treat narcolepsy (a long-term sleep disorder that disrupts normal sleeping patterns)
some medicines used to treat asthma, such as salbutamol,salmeterol and theophylline
A disturbed sleep pattern is one of the most common symptoms of jet lag.
After a long-haul flight, you may find it difficult to sleep at the correct times. For example, you may be awake at night and sleep during the day.
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.
Good sleep hygiene
Your GP will be able to advise you about what you can do at home to help you sleep. This is known as good sleep hygiene and includes:
establishing fixed times for going to bed and waking up (try to 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
only using the bedroom for sleeping and sex
If you have long-term insomnia (lasting more than four weeks) your GP may:
recommend cognitive and behavioural treatments
prescribe a short course of sleeping tablets for immediate relief or to manage a particularly bad period of insomnia; however, they aren't recommended for long-term use
Cognitive and behavioural treatments
The aim of cognitive behavioural therapy for insomnia (CBT-I) is to change unhelpful thoughts and behaviours that may be contributing to your insomnia. It may be recommended if you've had sleep problems for more than four weeks.
CBT-I can include:
stimulus-control therapy - which aims to help you associate the bedroom with sleep and establish a consistent sleep/wake pattern
sleep restriction therapy - limiting 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 - 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
CBT-I is sometimes carried out by a specially trained GP. Alternatively, you may be referred to a clinical psychologist.
You'll usually have four or five sessions of CBT-I, each lasting about an hour. As part of the treatment you may be asked to keep a daily record of your sleep (a sleep diary).
In the UK, there are a number of places that provide specialist sleep services such as CBT-I. These include:
Bristol General Hospital (BGU)
Guy's and St Thomas' London
Newcastle upon Tyne Hospitals (NUTH)
Oxford University Hospitals (OUH)
Papworth Respiratory Support and Sleep Centre (RSSC)
Sleeping tablets (hypnotics) are medications that encourage sleep. They may be considered:
if your insomnia symptoms are very severe
to help ease short-term insomnia
if the good sleep hygiene and cognitive and behavioural treatments mentioned above prove ineffective
However, doctors are usually reluctant to prescribe sleeping tablets because although they help relieve the symptoms of insomnia, they don't treat the cause.
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.
You should be prescribed the smallest effective dose possible for the shortest 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 sometimes cause side effects, such as a feeling that you're hungover and daytime drowsiness.
It's best to take sleeping tablets at night, before you go to bed. Sometimes, particularly in older people, the hangover effects may last into the next day, so be cautious if it's likely that you'll be driving the next day (see below for more advice about driving).
It's very easy to become dependent on sleeping tablets, even after a short-term course. Therefore, if you're taking sleeping tablets regularly (every night), you should consider reducing them or stopping them altogether. Speak to your GP 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 are tranquillisers that can reduce anxiety and promote calmness, relaxation and sleep.
These medicines should only be considered if you have severe insomnia or it's causing extreme distress.
Benzodiazepines will make you feel sleepy and can lead to dependency. Therefore, only short-acting benzodiazepines (with short-lasting effects) should be used to treat insomnia. Temazepam is the benzodiazepine that's often prescribed.
Benzodiazepines can have many potential side effects. See the link to temazepam above for a full list of possible side effects.
Z medicines are a newer type of short-acting medicines that work in a similar way to benzodiazepines. They include:
Zaleplon is licensed to treat people with insomnia who have difficulty falling asleep.
It should only be used at the lowest possible dose and for a maximum of up to two weeks.
Common side effects of zaleplon (affecting more than one in 100 people) include:
painful periods (dysmenorrhoea) in women
pins and needles (paraesthesiae)
Less common side effects (affecting more than one in 1,000 people) include:
apathy (lack of interest)
balance and co-ordination problems
changed sense of smell
hallucinations (seeing things that aren't real)
Zolpidem is licensed for the short-term treatment of debilitating insomnia or where it's causing severe stress.
It should only be used at the lowest possible dose and for a maximum of up to four weeks.
Common side effects of zolpidem include:
dizziness, nausea and vomiting
tiredness and sleep problems, such as sleep walking
Less common side effects include confusion and double vision.
Zopiclone is licensed for the short-term treatment of insomnia including difficulty falling asleep, waking up during the night and long-term insomnia that's debilitating or causing severe distress.
It should only be used at the lowest possible dose and for a maximum of up to four weeks.
Common side effects of zopiclone include:
metallic taste in your mouth
Less common side effects include:
dizziness, nausea and vomiting
Z medicines can also sometimes cause psychiatric reactions, such as anger, irritability, agitation, aggressiveness, delusion, nightmares and hallucinations.
You should stop taking your medication and see your GP immediately if you experience any of these psychiatric reactions.
There's little difference between Z medicines and benzodiazepines. If one doesn't work, swapping to another is unlikely to have a different effect.
The National Institute for Health and Care Excellence (NICE) guidance contains more about the use of zaleplon, zolpidem and zopiclone for the short-term management of insomnia (PDF, 83.3kb).
Antidepressants are sometimes prescribed for people with insomnia, and can be particularly useful if a person also has a history ofdepression.
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).
Circadin is the only medicine containing melatonin. It's licensed to treat insomnia and is only available on prescription for people who are 55 years of age 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.
Side effects of Circadin are uncommon but can include:
If you're finding these side effects troublesome, stop taking Circadin and contact your GP.
If you have insomnia, it may affect your ability to drive. Medical conditions that cause sleepiness should be reported to the Driver & Vehicle Licensing Agency (DVLA).
GOV.UK has more information about telling the DVLA about a medical condition or disability.
Sleeping tablets are usually only prescribed for the short-term treatment of insomnia
Complementary and alternative therapies
There's very limited evidence to suggest that either acupuncture orhypnotherapy are effective for treating insomnia.
Certain herbal remedies, such as chamomile and passionflower, have been reported to have positive effects. However, they haven't been thoroughly clinically tested, so their effectiveness and long-term safety is unknown.
Compare your options
Take a look at a simple guide to the pros and cons of different treatments for insomnia
Self-help for insomnia
Insomnia can often be prevented by changing your daytime and bedtime habits or by improving your bedroom environment.
Making small changes may help you get a good night's sleep. Try some of the methods below for at least three to four weeks.
Set a specific time for getting up each day. Stick to this time, seven days a week, even if you feel you haven't had enough sleep. This should help you sleep better at night.
Don't take a nap during the day.
Take daily exercise, such as 30 minutes walking or cycling, at least four hours before you go to bed. This will allow your body temperature to cool down.
Stop drinking tea and coffee four hours before bedtime.
Avoid drinking alcohol and smoking. Like caffeine, alcohol and nicotine are also stimulants. Alcohol may make you sleepy at first but will wake you up when the effects have worn off.
Don't eat a big meal or spicy foods just before bedtime. A small snack containing tryptophan (a natural sleep-promoting amino acid) may help, such as turkey, banana or fish.
Only go to bed when you're feeling tired.
Try to create a bedtime routine, such as taking a bath and drinking a warm, milky drink every night. These activities will be associated with sleep and will cause drowsiness.
Don't lie in bed feeling anxious about sleeping. Instead, get up and go to another room for a while and do something else, such as reading or watching television, before trying again.
Don't watch the clock because it will only make you anxious.
Write a list of your worries and any ideas to solve them, then try to forget about it until the morning.
Use thick blinds or curtains or wear an eye mask if the early morning sunlight or bright streetlamps affect your sleep.
Wear ear plugs if noise is a problem.
Don't use the bedroom for anything other than sleeping or sex. Don't watch television, make phone calls, eat or work while you're in bed.
Make sure your mattress is comfortable and that you have a pillow you like, plus adequate bed covers for the time of year.
When you find that you're asleep for most of the time that you're in bed, try going to bed 15 minutes earlier but make sure you get up at the same time in the morning.