Solutions for Insomnia, Updated 2020

What Is Known About Insomnia
Healthy Steps: Insomnia—First Steps
Healthy Steps: Insomnia—Full Program
Preventing Insomnia
From Dr. Deborah's Desk

Revised 22 August 2020

When was the last time you had trouble sleeping? Too much screen time, emotional stress, loud neighbors, or the anticipation of leaving on a trip can all interfere with a good night’s rest. But if you frequently have trouble going to sleep or staying asleep, you can count yourself among the one-third of Americans who suffer from insomnia. In the US, insomnia is the third most common health complaint after headaches and colds.

Either acute or chronic, insomnia involves problems with falling asleep, remaining asleep at night, waking early, or a combination of all three. Acute insomnia occurs only occasionally and is generally a response to emotional stress or excitement. Financial worries can keep you awake at night, but so can a positive life experience such as receiving a promotion. Temporary physical discomfort like a cold can cause short-term insomnia, as can jet lag. Even exercise can trigger insomnia if it takes place too close to bedtime. If your insomnia lasts only a night or two (or up to a month), you can rest assured that you're only suffering from temporary sleeplessness.

If your sleeping difficulties persist for more than a month, however, you're slipping into the territory of chronic insomnia. It's not unusual for people with chronic insomnia to suffer from disrupted sleep at least 3 nights a week. According to the National Sleep Foundation, people with chronic insomnia have problems sleeping more than 16 nights out of every month. That's a lot of lost sleep. Chronic sleep deprivation casts a wide net of problems, affecting work, relationships, leisure activities, and physical and emotional well-being.

Although prescription and over-the-counter sleep medications are widely promoted for sleep, I strongly recommend against their use. Even one night of relying on sleep medications can cause you to have more difficulty sleeping the following night, setting in motion a cycle of sleeplessness and drug dependence that can be difficult to break. Sleep medications are addictive, ineffective, and have potentially dangerous side effects, including an increased risk of accidents in the short term, and dementia later in life.

Sleep is a natural process, and your body will self-regulate if given the appropriate conditions for rest. Formulate a comprehensive program that includes diet, exercise, relaxation, and a variety of pleasurable suggestions that will help you create an atmosphere conducive to sleep. If necessary, there are also a number of natural supplements helpful for restoring healthy sleep patterns and eliminating insomnia.

What Is Known About Insomnia

There are many possible causes of insomnia, ranging from physical conditions to prolonged emotional distress. Simple environmental or lifestyle factors also commonly contribute to chronic sleep problems or may even be the sole cause of sleeplessness.

Sleeping well is a sign of good health, so it's no surprise that poor sleep is associated with many medical conditions. Acid reflux, sleep apnea, restless legs syndrome, pain caused by arthritis or fibromyalgia, respiratory diseases, an overactive thyroid gland, and an enlarged prostate are all obvious sleep disrupting conditions. Some medications can also cause insomnia-for example, diuretics, thyroid drugs, and antidepressants.

As we age, we become increasingly vulnerable to struggles with sleeplessness. Women are more than twice as likely as men to suffer from insomnia because of hormonal fluctuations of menopause. One of the most common and unrecognized causes of sleep disturbances is elevated cortisol. The adrenal glands secrete this stimulating hormone in excess in response to both stress and sleep disruption. Given our modern lifestyles of doing too much, staying up too late, being constantly exposed to artificial lighting, and watching television or working on the computer before bedtime, it's easy to see how we can get caught in a vicious cycle of stress and insomnia.

Another cause of insomnia is the "naturally" decreasing levels of melatonin, a hormone produced in the pineal gland of the brain that helps us fall asleep and stay asleep. Our modern lifestyle, as described above, conspires against healthy melatonin production. Sleeping in a dark room, avoiding exposure to any bright lights during late evening and night hours, and regular sleep schedules enhance our melatonin production. If you must use a light at night, red and amber shades of light are less disruptive to our brain's ability to promote sleep.

Update: Melatonin levels are also vulnerable to suppression when there is dysregulation of (here's a mouthful:) the hypothalamic-pituitary-adrenal (HPA) axis. Our adrenal glands make a varying amount of cortisol through the day. Cortisol wakes us up and gets us going in the morning and we make extra if we need to run from an attacking tiger... or catch a bus.. or meet a deadline... or silence a noisy cell phone in the movie. My point being that in our modern life, what used to be a rare extra stimulus for cortisol production might be a frequent occurrence in our modern world. Cortisol should normally decline as the sun goes down, and remain fairly low throughout the night. Some folks with high perceived levels of stress end up with high cortisol levels that don't properly quiet themselves at night, so we see higher cortisol levels in the evening and night when this HPA axis is out of sync with ideal. And cortisol suppresses melatonin. So if you're someone who can't turn off their mind at night, who startles awake in the middle of the night or even the morning, you might have HPA issues that overwhelm your natural melatonin cycles.

Not surprisingly, insomnia results in daytime fatigue, but that's the least of the problems caused by insufficient sleep. Insomniacs tend to have difficulty concentrating; are more irritable, anxious, and depressed; and are more likely to suffer illnesses ranging from headaches to heart disease to Alzheimer's Disease. They're also prone to both driving and work-related accidents. Memory is compromised as we lose time spent in deep or 'slow wave' sleep; creativity and productivity seem more dependent on REM sleep.

To break the cycle of sleeplessness and restore a pattern of healthful sleep, it's essential to address dietary factors, stress management, and exercise patterns as well as to adopt simple sleep hygiene techniques. Caffeine is near the top of the list of substances that negatively affect sleep, but it is equally important to avoid sugar and refined carbohydrates so blood sugar remains even. Fluctuating blood sugar stimulates the release of cortisol and causes middle-of-the-night awakenings. To ensure blood sugar stability, eat regular, balanced meals throughout the day and avoid eating for three or more hours before bed.

Healthy Steps: Insomnia—First Steps

For the greatest insomnia improvement with the fewest steps, do the following:

• Balance your blood sugar. Eat plenty of protein and healthful fats while avoiding sugar and refined carbohydrates, not just at dinner, but at every meal.
• Avoid caffeine. Stay away from excessive caffeine (coffee, black tea, green tea, chocolate) and avoid all sources of caffeine at least eight hours before bedtime.
• Decrease visual stimulation. Make your bedroom as dark and quiet as possible and turn off computer screens at least two hours before bed.  TV might be okay up to an hour before bed. Find a way to let stresses roll off of you like water off of a duck's back. 
• Establish a regular routine. A regular bedtime routine is essential; go to bed at the same time every night, dim the lights before bed (check out the app My Lux, and aim for evening levels around 50 or less), and keep the temperature in your bedroom below 70 degrees.

Healthy Steps: Insomnia—Full Program

A comprehensive insomnia treatment program involves many areas in which action steps can be taken, gradually or all at once. Start by following my basic nutrition and healthy lifestyle guidelines, with the following modifications:

Savor Helpful Foods

• Healthful proteins. Eat protein throughout the day to prevent hypoglycemia. Chicken with skin, fish with skin, beef, lamb, and pork are good choices; turkey contains tryptophan, which encourages relaxation.
• Healthful fats. Organic butter, coconut oil, extra virgin olive oil, and other beneficial fats provide satiety and keep blood sugar balanced.
• A gentle dose of carbs? If you are already on a low carbohydrate eating plan (this may be particularly true for women), sometimes you are a little too low for your adrenals to stay quiet all night. A remedy for insomnia in a low carb eater might be half a sweet potato with butter, eaten with your evening meal, at least 3 hours before bed.
• Organic milk and cheese, preferably raw. These dairy products contain tryptophan, an amino acid necessary for producing the neurotransmitter serotonin, which enhances relaxation. Choose goat or A2 dairy if you suspect any adverse dairy reaction.

Avoid Problematic Foods

• Caffeine. If possible, completely eliminate all sources of caffeine, including coffee, black tea, green tea, chocolate, and colas. Also avoid medications containing caffeine such as drugs for colds, migraines, and menstrual cramps. If you tolerate SOME caffeine, be sure to cut yourself off at least 8 hours before bed.
• Aspartame. This artificial sweetener suppresses the production of the neurotransmitter serotonin, which is essential for relaxation.
• Alcohol. Although alcohol has an initial relaxing effect and can help you fall asleep, it often wakes you up several hours later.
• Allergenic foods. If you suffer from food allergies (symptoms include eczema, chronic sinusitis, and migraines), you must identify and eliminate trigger foods because they can also affect sleep.

Supplements

• Barlean's High Omega Fish Oil. Take 1 tablespoon daily.
• Biotics Research Bio-D-Mulsion Forte Take 1-2 drops daily as needed to keep vitamin D levels between 40-65 ng/mL. Take your vitamin D in the evening to optimize melatonin productions. 
• Integrative Therapeutics, Clinical Nutrients HP. Take 2 capsules daily, with a meal.
• Metabolic Maintenance 5MTHF 5 mg. If you have a methylation-compromised genetic variant, take 5 mg of methyl folate with your evening meal supplements.

If you have trouble falling asleep:

• Designs for Health NeuroMag or Jarrow MagMind. This mineral supports muscle and nervous system relaxation, and is the form of magnesium most effective in the brain. Take 2 capsules at bedtime for sleep. Two capsules in the morning will help your brain function during the day.
• 5-hydroxytryptophan (50 mg) or L-Tryptophan (500 mg). Tryptophan is an amino acid precursor for the neurotransmitter serotonin and can help with both falling asleep and staying asleep. Take 1 capsule (50 or 500 mg) in the afternoon, followed by 2-4 capsules on a relatively empty stomach before bed for the first week. Then switch to a lower maintenance dosage of 2 capsules at bedtime. It may take three weeks to notice obvious results. If desired, try three days on followed by four days off; studies indicate this can be effective long-term. Thorne's 5-HTP and Pure Encapsulations L-Tryptophan both vitamin B6: if you have troubling or unremembered dreams, you might remedy that with this version of tryptophan.
• Melatonin.  I like the melatonin made by Thorne Research and Source Naturals and others at my store. I'm not linking because I want to say something about dose. When you're 30 or under, use 0.5-1.0 mg for no more than a couple weeks at a time. If you're 40 or over, feel free to use doses of 0.5-15 mg as needed because your own production of melatonin has declinded.
• Thorne Research Niacinamide. Take 1-2 with the 5-HTP before bed; the combination may be more effective than either alone. Do not take more than 1000 mg (2) of niacinamide without the supervision of your doctor.
• Gaia Herbs Sleep Thru. Take 1-3 softgels half an hour before bed if you're not feeling ready for sleep.
• Designs for Health Glycine powder. One-half teaspoon of powder readily dissolves in liquid and will provide 3 grams of glycine, very helpful in getting to sleep AND staying asleep. We need lots of glycine, and never get enough. Good sources are poultry skin and cartilage, bone broth, and collagen powder. See if the pure Glycine Powder works well for you. Here's a great article about all the wondrous benefits of glycine!
• Designs for Health Inositol powder. Take 1/2 tsp of this easily dissolving liquid before bed, or in the night if you awaken.

If you have trouble staying asleep:

• Protein/Fat Snacks. To promote and maintain blood sugar balance, snack on small amounts of protein and fat (nuts, olives, turkey, raw cheese) every two hours throughout the day and evening.
• Optimal melatonin. When your sleep problem becomes chronic the optimal dose of melatonin is 0.3 mg of a sustained release melatonin, taken 7-8 pm in the evening, available from compounding pharmacies or through my office.
• Source Naturals L-Theanine. L-theanine helps the brain make its own GABA when it is under stress.. Take two capsules at bedtime and 1-2 if you wake in the night.
• Integrative Therapeutics Phosphatidylserine. Take 1-3 at bedtime or up to 4 hours before bedtime as an additional cortisol tamer for middle of the night wakening. Take 1-2 on waking, up to a maximum of 4 tablets a day: your middle of the night dose will likely disappear as healthy sleep habits are restored.
• Source Naturals GABA Powder. Source Naturals' well-absorbed form of GABA can be taken in tiny amounts, 1/8 tsp, in water at bedtime or in the event of night time waking, particularly when you are anxious or worried. Theoretically, GABA does not enter the brain easily, so if this supplement really helps you it should be considered a short term solution while you evaluate what might be opening the doorway to your brain: consider some source of systemic inflammation. Thorne Research makes a product called PharmaGABA which is more effective at crossing into the brain and is often effective when regular GABA is not.
• Source Naturals Glycine. The amino acid glycine can help with achieving and sustaining deeper levels of restful sleep. Take 2000-3000 mg at bedtime. Glycine is thought to work by lowering core body temperature, akin to sleeping in a cooler room and yielding greater sleep satisfaction.
• CBD in an organic and pure form, I recommend CBD without THC although some people seem to do really well with a mixture. My reservation is that in terms of sleep studies, we're fairly certain CBD convers "natural sleep" without cognitive adverse effects; we are not so sure of THC, it has mixed results. (I suspect it's in your genes how you respond to THC, all my life it's been a stimulant!) My favorite is the CFH Brand CBD on my website:  I'll use a 25 mg capsule at bedtime if I don't feel properly relaxed. I'll take a dropperful of the liquid if I wake in the night.
• Re-direct reflux. One of the most common causes of night-time waking in older people (or anyone who overeats at night) is digestion backing up, causing either reflux or simply abdominal distention. Our intestinal tract is meant to be empty at night, in recovery mode. You can enhance its downward, cleansing action with Iberogast, 10-40 drops taken at bedtime.
• Relax your bladder. Older men and women have different reasons that they need to wake frequently and empty their bladder. Women's night time bathroom visits can often be reduced by restoring estrogen to the vaginal and urethral tissues. I like to prescribe vaginal estriol as the most safe and effective means to restore youthful bladder function. Men might need to address issues of prostate enlargement with either supplements such as palmetto, or prescriptions to restore testosterone or lower estrogen that has crept up too high.

Lifestyle Choices

The long list of suggestions here reflects human variability: read through the list and pick the suggestions that could make the biggest change in your life. Start with those.

• Avoid blue light in the 3 hours before bed. By blue light, I mean that light coming from an electronic screen, whether a tablet, a computer or a television. (Some e-readers are not backlit and are non-stimulating for some people.) The blue light travels from non-visual receptors in your retina to suppress melatonin production in the pineal gland. If you must use a screen, wear orange sunglasses identified as "blue-blocking lenses".
• Train your brain. Meditation is the best studied form of brain training: pertinent to sleep, it has been shown that meditation, particularly in the evening, can raise nocturnal levels of melatonin. See the article here for some simple how-to's if you're new to meditation. Plugging in to a "Binaural" sound track is an alternate method that has been studied much less thoroughly. Used pre-operatively, the addition of (subliminal) discordant rhythms to a pleasant sound track has additional benefits in terms of reducing patient anxiety. I like the program Brain Wave, and listen to a soundtrack for motivation or creativity when I'm working, a relaxation track when I'm reading in the evening.
• Exercise. Engage in one hour of exercise daily but avoid exercising just before bed to prevent overstimulation. It is said that morning exercise helps you fall asleep and late afternoon exercise helps you stay asleep.
• Regulate temperature. Keep your bedroom at a cool 68 degrees or less but don't let it get too cold. When sleeping with a partner, use separate blankets to regulate temperature for individual comfort if necessary.
• Increase air circulation. Open windows or use a fan to keep air moving.
• Warm your feet. In winter, use a hot water bottle to warm your feet.
• Use natural bedding. If possible, sleep on organic bedding, including an organic mattress to avoid exposure to the toxic chemicals used as fire retardants in conventional mattresses. Wool blankets are best for temperature regulation; cover with silk or cotton duvet covers. Wool pillows (especially a rectangular supportive neck pillow) are excellent for sleeping. Reserve electric blankets or pads for warming the bed before you get in, and then turn them off.
• Increase darkness. Dim lights in the evening several hours before bedtime to raise prolactin levels. Use blackout curtains to raise melatonin levels; if necessary, use an eye mask with shaped eye pockets so lids can move easily in REM sleep. If you need a night-light, use one with a red bulb.
• Create quiet. Create a peaceful, quiet space by unplugging all equipment and removing alarm clocks and phones. If necessary, use earplugs. A white noise machine is useful when sleeping with a snorer or if there is unavoidable neighborhood noise.
• Cultivate relaxation. Avoid overly stimulating movies, television shows, or books at least one hour before bedtime. Stop using the computer at least two hours before bedtime. Take a shower and wash away the stress of the day.
• Massage with Ancient Minerals Massage Oil. If you have muscle tension or soreness, apply a few sprays of magnesium oil (may sting briefly on some skin) and rub it in. It is a long-acting form of magnesium that is well-absorbed and can have an immediate as well as a cumulative effect.
• Take a bath. A warm bath with lavender oil relaxes body and mind. Add 5-10 drops of lavender essential oil to the bathwater and breathe deeply. You can also put a drop of lavender oil on your pillow or spray your face lightly with lavender mist. Not too much heat close to bedtime, but gentle heat an hour earlier will give your body time to cool off and sleep.
• Establish a bedtime. Try to go to bed at the same time every night and to rise at the same time each morning. Ideally, go to bed by 10 pm and rise before 7 am.
• Create a soothing environment. Decorate your bedroom in calming colors of blue, green, and lavender and clear out clutter to make a peaceful haven for sleep. Use your bed only for sleep or sex, not for activities such as work or watching television.
• Wear rose-colored glasses. Spend part of every day outdoors without sunglasses to increase absorption of vitamin D. Wearing rose-colored lenses will enhance melatonin production by up to 60 percent.
• Try yoga for relaxation. Yoga calms the body and mind; forward-bending yoga poses are particularly helpful when preparing for sleep. Soothing music is another good option for cultivating relaxation.
• Avoid heavy evening meals. Eat dinner by 7pm to allow plenty of time for digestion before sleep.
• Have a snack. A light bedtime snack of protein and fruit will keep blood sugar balanced and prevent hypoglycemia during the night. Protein sources that contain tryptophan are best for encouraging serotonin production (turkey, raw cheese, and raw milk). Low carb eaters, already well satisfied with protein over the day, might actually do well with a complex carbohydrate - not a grain but half a sweet potato, with butter - taken with or just after dinner.
• Curb fluid intake. To prevent getting up in the night to use the bathroom, limit your fluid intake during the hour before bedtime.

Homeopathic Treatment for Insomnia

In general, homeopathic treatment of insomnia requires professional consultation. However, if you find you have occasional “excitement” insomnia, or are unable to sleep because of something exciting, good or bad, yesterday or tomorrow: take Coffea 30C two pellets and see how quickly sleep returns. May repeat once more in the night.

Insomnia Prevention

The best way to encourage sleep is to adopt good “sleep hygiene” habits. Cultivate a regular routine at bedtime: Go to bed at the same time every night and take a warm shower or bath shortly beforehand. Find a way to gradually wind down from the stresses of the day, and try to avoid “brain work” such as reading emails or working on projects in the late evening. Avoid anything that raises body temperature or speeds up the heart-such as vigorous exercise-at least 2 hours before bed. If you read or watch television to unwind, be sure to avoid violent reading material or television programs.

Lowering the lights in your home a couple of hours before bedtime triggers your body to increase levels of melatonin, a hormone that prepares you for sleep. Sleeping in a completely darkened room keeps melatonin at a high level throughout the night and facilitates deep and restful sleep. If possible, go to sleep before 10 pm and allow yourself to awaken naturally with the sunrise.

Maintain good blood sugar control throughout the day by emphasizing proteins, healthful fats, and vegetables and minimizing sugars and processed carbohydrates. Avoid caffeine, particularly in the afternoon and evening, and excessive alcohol. A small snack of protein and fruit before bed can help maintain blood sugar at a healthy level throughout the night.

If you need to take something to help you sleep, avoid prescription drugs; instead try the natural supplements suggested above. Most of all don't fret if you can't sleep. Lying in bed and worrying about not sleeping will only increase your anxiety, stimulate the production of cortisol, and make it impossible to sleep. If you go to bed and find that you aren't asleep within 30 minutes, get up and do something relaxing like reading a book (choose something boring) or listening to soothing music. Avoid turning on bright lights, though, which will decrease melatonin and cue your body to awaken. Follow the program we've outlined above, and you'll once again be sleeping like a baby.

As the medicinal uses of marijuana have been studied, the non-intoxicating effects of the isolated cannabinoid (CBD) component has been found to be helpful for some people to facilitate and deepen sleep. Widely available in some states, and by internet order from all, oils high in CBD can be used orally or topically. Cannabinoids are known for their anti-inflammatory properties and lack any of the mind-altering effects associated with the THC portion of cannabis, minimal to non-existent in CBD preparations. You can find various CBD preparations online.

From Dr. Deborah's Desk:

Many people take a sleeping pill one time or another, but no one really likes taking sleeping pills. There are two, and only two,  medications that we are fairly sure confer natural sleep and do not have long term side-effects for most people.  One is Trazodone (routinely used as an anti-depressant) and Gabapentin (used for nerve pain or seizures).  Both work in lower-than-average doses when it comes to sleep and the results, and this is true for every single drug in the world!!!, are individual. I have seen people require low doses of Gabapentin (100 mg) or high (600)... I have seen it improve mood or be neutral and about 10% of people respond with a decline in mood.  Ditto for Trazodone, though the dosage range is much lower.  You'd need a prescription for either one of these. 

The two most important lifestyle points I would highlight are keeping the same rising time every day and dimming the lights and avoiding the computer through the evening hours. Logical and effective both, our bodies seem to relax better when we unwind from the day gradually over the evening hours. Dimmer lights in the evening offer a closer parallel to truly living with the sun.

The list of potential supplements that can aid sleep is a daunting list: "Do I have to take ALL of those?" Thankfully, no! As our skills in personalized medicine improve, we will be able to make more targeted recommendations, but for now it's a bit of trial and error, or consultation with a knowledgeable physician. Hopefully you will rotate through some of the suggestions, and find a combination of lifestyle modification (ALWAYS crucial) and a supplement or two, and that combo will lull you into a deep and dreamy sleep, happy dreams!

I had been advising John for years - 20 to be exact - that his nightly Clonazepam might be a small amount, but as a drug it was highly addictive, meaning it could reasonably be exerting some effect on him the subsequent day. He finally decided he'd switch, with great trepidation. I sent him home with 5-HTP, Melaton-5 and a gentle herbal combination supplement, suggesting he start them one at a time and change his clonazepam to an alternate night strategy. Urgent telephone call the next weekend, because he was sleeping so well with two of the 5-HTP, one Melaton-5 and one of the Thorne Research Seda Plus, he was sure they were addictive, too, and he wanted to know if he had to worry about getting off of them in the future. I assured him he could even take extra if he ever needed to, with no worry of ill effects. I asked him about a year later if he saw any difference. He says that even though his finances are as bad if not worse than ever, he doesn't fall into the pit of anxiety he used to, and for that he credits the change in sleep regimens.