Insomnia is defined as a difficulty falling or maintaining sleep (the latter being more common) that lasts for at least one month and causes significant daytime impairment. Such individuals usually suffer fatigue, difficulty concentration, irritability, day time sleepiness, and headaches. There may also be frequent awakening episodes with difficulty returning to sleep after awakening, or awakening too early with inability to return to sleep, despite adequate opportunity to sleep.  Overall, it is one of the most prevalent health conditions and more common in females, the older population (over 60 years of age), and among African Americans.

It is subdivided into Primary (not caused by underlying psychiatric or medical condition, or substance abuse) or Secondary (due to another medical or psychiatric condition such as depression or another sleep disorder).

35 - 44% of individuals presenting to a sleep specialist may have an underlying secondary cause for their insomnia, emphasizing the need to screen for these conditions. Causes of secondary sleeplessness include:

• Anxiety
• Arthritis
• Acid reflux
• Asthma
• Congestive heart failure
• Depression
• Fibromyalgia
• Hyperthyroidism
• Medications
• Menopause
• Migraine
• Pain
• Restless leg syndrome
• Sleep apnea
• Stroke
• Skin condition causing itching
• Urinary incontinence
• Unusual sleep behavior (sleep walking)

Additionally, there are several medications or substances that may disturb sleep, including:  alcohol, caffeine, chemotherapy agents, diuretics, illicit drugs, nicotine (tobacco), pseudoephedrine (common in decongestants), steroids, and stimulant laxatives.

Environmental factors that may adversely affect sleep include:

• A bedroom environment with too many stimuli.  Temperature that is too cold or hot, bright light, noise, and pets can impact quality of sleep.
• Snoring of a partner can be disruptive.
• Unusual sleep time, such as night or rotating work shifts, and travelling across multiple time zones, can affect sleep.

In order to evaluate this condition, it is recommended to keep a sleep diary to record time going to bed and waking up, time taken to fall asleep (abnormal if taking more than 30 minutes to initiate sleep, the number and duration of awakening episodes, and the percentage of time spent in bed sleeping (for this component, normal sleep efficiency is defined as more than 85%).

The good news is that there are several steps those suffering from insomnia can take, including behavioral techniques and medications. 

• Better Sleep hygiene:  go to sleep and wake up at the same times each day despite having a sleepless night the day before, avoid stimulant ( caffeine - no more than 2 cups per day, avoid smoking, avoid narcotics ), limit alcohol intake to 1 drink per day, avoid day time naps, and schedule regular exercise preferably 4-6 hours prior to sleep. It is also recommended to keep one's bedroom dark and quiet.
• Changing sleep behavior: use the bedroom for sleep only, no watching TV, reading books, talking on phone, etc.  If unable to sleep for 10-20 minutes, leave the bedroom  and return when feeling sleepy only. Setting the alarm for wakeup at a regular time every day and refraining from using the snooze button are also recommended.
• Relaxing training:  set aside a time to relax before bed to use relaxation techniques. It helps to reduce muscle tension, and should be accompanied by paced breathing (slow inspiration and prolonged expiration) for maximum effectiveness.
• Cognitive therapy:  challenge and replace dysfunctional beliefs (such as an apprehensive belief that sleep can not be controlled) with positive affirmations involving sleep.
• Light therapy - this technique uses artificial light to adjust and regularize the biological clock

Prescription Medications should be avoided and considered as a last resort.  These should be prescribed for as minimum a time period as possible to help regulating sleep cycle, or to address an underlying medical condition after careful review by a health care provider and under his or her supervision. These medicines carry potential hazards and side effects. After careful review, the doctor may decide to choose a medicine from an appropriate group.

Common medication groups for sleeplessness are:  Benzodiazepines such as Ativan (Lorazepam), Restoril (Temazepam), Halcion (Triazolam); Non Benzodiazepines such as Ambien and Lunesta; Antihistimine drugs including Benadryl, Unisom, and Vistaril; and Antidepressants for sleeplessness including Amitryptiline, Trazodone, Mirtazepine (Remeron).  Anti-seizure medicine as Neurontin is also prescribed sometimes to assist with sleep.  Sedating Antipsychotics such as Seroquel at times are also used as sleep aids.

There are several natural or over the counter remedies to consider.  Herbs and Natural Supplements such as Melatonin and Valerian root are also utilized to improve sleep.  Melatonin is a hormone naturally secreted during the night which generally benefits sleep initiation but not maintenance.  Derivatives of the Valerian root are often used by some to treat anxiety and promote sleep.  Anthihistimines, as mentioned previously, can be effective alone or in combination with an over the counter pain reliever, such as Tylenol.

It is important to partner with one's Primary Care Physician to evaluate and treat insomnia, especially if an underlying medical condition is part of the cause.  Through a combination of behavioral and/or medication therapies, individuals with insomnia will be on the right path towards a good night's sleep.