In the treatment of sleep problems, it is always best to first try non-pharmacologic options so there is no danger of side effects. The first step is to adopt standard
sleep hygiene techniques that have been shown to be effective. These include, first, maintaining a regular sleep wake cycle, so that the time one goes to sleep and wakes up vary by only an hour from night to night. This prevents disruption of circadian rhythms, the changes in our endocrine systems during the day, and improves sleep. Next, one should exercise regularly, but not within several hours of going to sleep. One should avoid daytime naps, because they can interfere with sleep at night, and should avoid heavy meals within a couple of hours of going to bed. It is important to avoid stimulants, such as caffeine within at least 3 or 4 hours of going to sleep. Some people who are particularly sensitive may have to restrict caffeine to the early morning or decrease its use, sometimes even eliminate it. One should work to create a comfortable, quiet, dark and temperature controlled bedroom and develop a relaxing routine for the hour before getting into bed. In addition, it is best to use the bedroom only for sleep and sexual activity. It is also best to avoid alcohol within several hours of going to sleep. While alcohol can help with sleep onset, it often leads to early morning awakening and it disrupts the quality of sleep. Finally, it is best not to stay in bed if you are having trouble sleeping beyond 20-30 minutes. At that point it is best to get up and attend to a quiet activity such as reading a book or watching television. Once you become tired and feel sleep coming on, it is time to get back in bed.
If none of these techniques seem to help, it is a good idea to discuss the sleep problem with your physician. There are a number of medical problems that can disrupt sleep such as pain, sleep apnea disorder, restless leg syndrome and endocrine illnesses. There are also medications for particular medical problems that can cause insomnia. Depression and anxiety can also disrupt sleep. If your physician does not believe you are struggling with these illnesses or medication side effects, then one may want to consider working with a talk therapist to learn relaxation skills or other strategies to help relax while going to sleep. Finally, there are a number of medications that can be prescribed to help insomnia.
The first group of medications that can help with sleep are known as benzodiazepines. These include such medications as temazepam (Restoril), flurazepam (Dalmane), estazolam (Prosom), triazolam (Halcion), and quazepam (Doral). These are drugs which interact with the neurochemical GABA to cause sedation, memory loss, a decrease in anxiety, and they can be muscle relaxants and antiseizure drugs. These drugs vary in their onset and length of action. Temazepam, for example, is most effective when it is used to help with sleep onset, whereas flurazepam is most effective in helping someone stay asleep. These medications tend to lose their effectiveness over time and the associated effects such as memory problems and sedation can carry into the next day.
There are several non-benzodiazepines that can also be effective in the treatment of insomnia. These include zolpidem (Ambien), zaleplon (Sonata), eszopicione (Lunesta) and ramelteon (Rozerem). The first three drugs work primarily by binding to a particular subunit of GABA. Zaleplon has the fastest onset of action, but it is very short acting. Zolpidem also has a rapid onset of action, but not quite as quick as zaleplon, and it lasts a bit longer. Eszopicione also has a reasonably fast onset of action, but it lasts significantly longer than zolpidem or zaleplon. The advantage of a longer onset of action is that it will help avoid early awakening, however, it may mean its sedating effects will still be present the next morning. These medications do not have the same memory effects as the benzodiazepines and there is controversy about whether they lost their effectiveness over time. Ramelteon is a new medication that stimulates melatonin receptors. Melatonin is a substance in our body that helps modulate the circadian rhythm, the endocrine changes in our body through the day. It plays a key role in the sleep wake cycle, and taking melatonin itself has been popular to help with sleep. Unfortunately, taking melatonin itself does not seem to help with sleep, perhaps because it is metabolized quickly. Ramelteon has a fairly rapid onset of action, and it lasts for an intermediate amount of time in comparison to the other medications discussed. There are a number of over the counter medications for sleep such as the antihistamine Benadryl, but they either do not work effectively or interfere with the quality of sleep. If you do choose to try an over the counter product, it is important to inform your physician. These medications can interact with other medications so if you are going to be taking them regularly, the dosages of other medications may need to be adjusted.