Insomnia 101: What You Need to Know to Get a Good Night’s Sleep

Insomnia 101: What You Need to Know to Get a Good Night's Sleep-main photo

Welcome to the Decision Guide for Insomnia!

This guide was not designed to substitute for office-based care. Rather, the purpose of this advice guide is to assist you in getting the most out of a medical evaluation from your doctor.

Persistent insomnia can arise from a variety of causes, including some serious medical conditions. If you have insomnia that persists for longer than a few weeks, insomnia that is accompanied by physical symptoms during the night, or insomnia that interferes with your daytime wakefulness and function, you should be evaluated by a doctor. If this is your situation and you have not already done so, please take the time today to arrange a medical evaluation.

Most of the time, insomnia does not require treatment with medication as long as you can identify and eliminate the problem that is interfering with normal sleep. By completing our advice program before your evaluation, you may be able to more clearly identify symptoms or features about your insomnia that are clues to its cause. Our goal is to help you proceed more quickly with your doctor toward the tests or procedures that can correctly identify the cause. This guide can not adequately consider significant previous medical history that you may have. With a more full understanding of your past health, your own physician may choose a different path to evaluate your symptoms.

You will encounter a number of questions about your symptoms as you proceed through this program. Your answers to these questions will help us to personalize our recommendations for you.

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To begin thinking about your insomnia, we should know whether the problem is brand new, or whether this has been a recurring problem.

How long have you had your symptoms?

I have had my symptoms for less than one month.

A month or longer.

One of the most common causes of insomnia is excess caffeine.

Do you drink caffeinated beverages (cola, coffee, or tea) after lunch?

Yes, I do drink caffeinated beverages after lunch.

No, caffeine is not the cause of my insomnia.

New insomnia can be a side effect of a medicine that stimulates your central nervous system, although not all people will experience this side effect. Please review the following list of medicines that can stimulate the central nervous system:

  • decongestants such as pseudoephedrine or phenylephrine (Sudafed, Sudafed PE and other brands)
  • drugs for smoking cessation such as nicotine or bupropion (Zyban, Wellbutrin)
  • antidepressant drugs
  • asthma medicine (inhalers, albuterol, or theophylline)
  • prednisone
  • beta-blocker medications such as atenolol (Tenormin), propranolol (Inderal), metoprolol (Toprol) or others
  • clonidine (Catapres), most commonly prescribed for blood pressure
  • thyroid replacement
  • anxiety medicine
  • diet or weight loss pills
  • medicine for attention deficit disorder such as methylphenidate (Ritalin, Methylin, Metadate, Concerta), atomoxetine (Strattera) and others
  • medicine for narcolepsy such as drugs containing dextroamphetamine (Dexedrine, Adderall), modafinil (Provigil), and others
  • migraine medication
  • medicines for Parkinson’s disease.

Are you taking any medications from the categories that are listed?

Yes, a medicine change may be the cause of my insomnia.

No, I don’t take any of these medicines.

Do you think you may be drinking too much alcohol?

Yes, I do.

I do not.

Caffeine can stay in your system for many hours after you consume a caffeinated beverage, and it is one of the most common causes of insomnia. Before you try other strategies to reduce your insomnia, it would be practical for you to eliminate caffeine outside of morning hours.

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One of the most common causes of insomnia is excess caffeine.

Do you drink caffeinated beverages (cola, coffee, or tea) after lunch?

Yes, I do drink caffeinated beverages after lunch.

No, caffeine is not the cause of my insomnia.

Insomnia can be a side effect of a medicine that stimulates your central nervous system. Please review the following list of medicines that can stimulate the central nervous system (not all people will experience this side effect):

  • decongestants such as pseudoephedrine or phenylephrine (Sudafed, Sudafed PE and other brands)
  • drugs for smoking cessation such as nicotine or bupropion (Zyban, Wellbutrin)
  • antidepressant drugs
  • asthma medicine (inhalers, albuterol, or theophylline)
  • prednisone
  • beta-blocker medications such as atenolol (Tenormin), propranolol (Inderal), metoprolol (Toprol) or others
  • clonidine (Catapres), most commonly prescribed for blood pressure
  • thyroid replacement
  • anxiety medicine
  • diet or weight loss pills
  • medicine for attention deficit disorder such as methylphenidate (Ritalin, Methylin, Metadate, Concerta), atomoxetine (Strattera) and others
  • medicine for narcolepsy such as drugs containing dextroamphetamine (Dexedrine, Adderall), modafinil (Provigil), and others
  • migraine medication
  • medicines for Parkinson’s disease.

Have you recently initiated any medications from the categories that are listed?

Yes, a medicine change may be the cause of my insomnia.

No, I have not recently started to take any of these medicines.

Insomnia can also be a symptom of withdrawal from certain medicines. This occurs when the medicine is discontinued, if your brain has adapted to a sedating or hormonal medicine. Please review the following list of medicines that can cause your brain to adjust its chemistry, resulting in insomnia for a period of time after the medicine is stopped:

  • anxiety medicines
  • antidepressant medicines
  • narcotics
  • estrogen.

Have you recently discontinued any medications from the categories above?

Yes, a medicine change may be the cause of my insomnia.

No, I have not recently stopped any of these medicines.

Usually, insomnia problems that have only been present for a few days or weeks arise from one of two sources.

The first source is a change in your living and sleeping “environment.” Your sleep “environment” includes everything that orients your brain to your schedule and conditions your brain to anticipate sleep:

  • your work and eating schedule
  • adjustment to travel, including jet-lag
  • your exercise frequency, duration, and timing during the day
  • noise in your sleeping location
  • light in your sleeping location
  • your bedtime ritual
  • stimulation prior to sleep, such as reading or viewing television
  • a new bed or mattress
  • change in room temperature
  • unpleasant odors in the bedroom.

The second source of short-term insomnia is an increase in emotional stress. This can arise from a stressful life event, relationship difficulties, performance anxiety, work or school stresses, a medical illness, or a mental illness such as depression.

Considering your own situation, which category would you consider the most likely source of your sleep disruption?

A change in sleep “environment.”

A recent increase in emotional stress.

Neither category fits me well.

The next possibility we will consider is whether smoking, drugs, or alcohol could be affecting your sleep pattern.

Any substance that affects your level of mental arousal can interrupt your normal sleep pattern. Sleep can be disrupted by the chemical effects of a drug, by a rebound in normal brain chemistry when a drug effect wears off, or in some cases, by drug cravings.

Alcohol is the substance that most frequently interferes with a normal sleep pattern, particularly if you drink an excessive quantity.

If you are a man, regular consumption of more than 14 drinks per week (or more than four drinks in one day) is excessive.

If you are a woman, regular consumption of more than seven drinks per week (or more than three drinks in one day) is excessive. Women absorb alcohol from the digestive tract more efficiently than men do.

Alcohol “night-caps” are particularly disruptive to a sound, full night’s sleep.

Do you smoke, use drugs, drink excessive alcohol, or consume alcoholic beverages in the evening?

Yes, I do.

I do not.

In order to further consider your insomnia, it will be helpful to know the specific pattern of your sleeping problem. Please choose your most bothersome symptom:

I have trouble getting to sleep in the first place.

I have trouble staying asleep. I wake repeatedly in the night.

I wake up too early in the morning.

I may sleep a long time, but I do not feel well rested.

Many medical conditions result in fatigue even though the length and quality of sleep seems to be normal. For your symptom, you will probably receive more useful information if you complete our Health Decision Guide on Drowsiness.

You have identified early morning awakening as your major sleep problem.

If you feel well rested in the morning, your sleep length may be all that you require. People vary in terms of the amount of sleep that they require, and your body will awaken you if it has rested adequately for your needs.

We will assume that you do not feel well rested upon awakening.

Do you feel depressed on most days or feel a lack of interest in activities that were previously enjoyable for you?

Yes, I feel depressed.

No, I do not feel depressed.

Occasionally, physical symptoms are the cause of early morning awakening.

Do you awaken due to chest pain?

Yes, I awaken due to chest pain.

No, I do not awaken due to chest pain.

Chest pain upon awakening is always concerning until it is explained, because it may result from coronary artery disease. You should discuss your symptoms with your doctor if you are over fifty or have other risk factors for heart disease, such as smoking, high blood pressure, diabetes, or a family history.

Some people have an increase in blood pressure during the night due to shifts in hormones. Early morning is the time that the blood pressure commonly peaks if a blood pressure rise occurs. This can provoke angina. Angina is the symptom of pain from inadequate oxygen delivery to a part of the heart.

Early morning awakening can be a symptom of depression. You should discuss your depression with your doctor and consider treatment options.

Your repeated awakenings may arise due to a medical symptom. We will explore several possibilities.

Are you breathing heavily or catching your breath each time you awaken?

Yes, I awaken with a need to catch my breath.

No, I do not sense a need to catch my breath.

Chest pain is always concerning until it is explained, because it may result from coronary artery disease. You should discuss your symptoms with your doctor if you are over fifty or have other risk factors for heart disease, such as smoking, high blood pressure, diabetes, or a family history.

Some people have an increase in blood pressure during the night due to nocturnal shifts in hormones, and this can provoke angina. Angina is the symptom of pain from inadequate oxygen delivery to a part of the heart.

Less concerning causes of chest pain are also possible. A very common example is gastroesophageal reflux disease (GERD, acid reflux), which can be provoked by lying flat.

Another symptom that can cause repeated awakenings is discomfort in the feet or legs. Discomfort could include burning or aching pain, cramps, or a need to keep the legs in constant motion due to a restless feeling in the legs.

Do you have discomfort of any kind in your feet or legs?

Yes, my feet or legs are uncomfortable.

No, I do not have these symptoms.

Are the majority of your awakenings related to a need to urinate?

Yes, this describes my situation.

No, I do not have this symptom.

You have already been asked if you are awakened by pain in your chest, and you have been asked about pain in your legs or feet.

Are you being awakened by pain anywhere other than your chest, legs, or feet?

Yes, I do have pain that keeps me awake.

No, I am not awakened by pain at all.

Many women have dramatic insomnia during the time that they are going through menopause. Insomnia is usually caused by hot flashes, which are bursts of a sensation of heat that is commonly felt in the upper body and face.

Are you a woman and if so, are you having hot flashes?

Yes, I am a woman with hot flashes.

No, this is not my problem.

Sometimes nightmares are dramatic enough that they can wake you from sleep.

Are you awakening with nightmares or fears?

Yes, this describes my situation.

No, this does not describe my situation.

Some conditions that repeatedly interrupt sleep cause severe sleep deprivation. In this case, you may have difficulty staying awake during the daytime and have a higher risk for dangerous accidents. Some sleep disorders can also put you in jeopardy of accidents during the night, if they involve “sleepwalking.” It is important to identify sleep problems that increase your risk for accidental injury.

The following symptoms suggest a sleep disorder that could put you at risk for an accident

  • daytime sleepiness that is severe enough to cause you to “nod off” during activities.
  • episodes when you feel you are paralyzed (unable to move) when you are in bed and nearly asleep.
  • abrupt collapse during the day due to unexplained temporary paralysis of your muscles
  • hallucinations (visions that are not real)
  • sleepwalking (If you “sleepwalk” you leave your bed while you are still asleep, and you may find yourself in any other location or find you have completed a complicated task when you wake up in the night or morning.)

Do you have any of the symptoms above that would suggest your sleep problem could put you at a high risk for accidents?

Yes, I do.

No, I do not.

You may be able to adjust your daily routine to help yourself sleep more soundly. The next several questions will review this possibility.

Do you exercise on most days?

Yes, I exercise on most days.

No, I do not exercise on most days.

Because your sleep problem is jeopardizing your safety, you need to have a full evaluation by your doctor or a specialist.

Unless you are able to easily identify a problem that explains your sleeping problems, it would be reasonable for your doctor to consider having your sleep formally observed by a specialized technician. Many medical centers have laboratories that are designed to monitor people with insomnia during their sleep. These “sleep labs” can identify changes in your breathing, heart rate, and brainwave pattern during sleep and can help to identify a specific cause of sleep interruptions.

Examples of serious sleep disorders include sleep apnea, narcolepsy, and parasomnia (sleep with sleepwalking).

Nightmares do not usually signify a medical or mental health problem, but when nightmares are recurrent it is worth considering whether you are having significant problems with depression or anxiety. One condition that commonly causes nightmares is “post-traumatic stress syndrome.” In this case, the nightmares may be flashbacks to a severely stressful or painful event, but they do not have to be.

It is appropriate to discuss your symptoms with your doctor. In addition to addressing your mental health needs, you should consider these strategies to improve your sleep

  • Seek training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order.
  • Avoid going to bed hungry.
  • Avoid daytime naps, and sleep only as much as you require.
  • Maintain a regular bedtime.
  • Establish an active daytime lifestyle that allows you to go to bed ready for rest. It is preferable that you complete any vigorous exercise four or five hours prior to your bedtime.
  • Reduce the mental stimulation that you experience after you have put yourself to bed. This means discontinuing bedtime television, reading, and conversation.
  • Reduce noise stimulation within your bedroom. This may require the use of a device that can drown out interesting noises with a monotonous sound, such as a fan or a radio that is tuned to static between stations.

Most people who are reacting to emotional stress do not require medications to assist with sleep and find relaxation techniques or therapy sessions to assist in stress management most helpful. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from treatment by a therapist or prescription treatment for your depression or anxiety. Some depression treatments are particularly helpful at assisting with insomnia. If you decide with your physician that a prescription sleep aid (“sleeping pill”) may be helpful and it is one that is not also an antidepressant medicine, it is appropriate to use the sleep aid only for a short term (typically less than two weeks). Some doctors recommend sleeping pills during the time that a prescribed anti-depressant medicine has not yet had its full effect. Over-the-counter sleep treatments can cause symptoms that persist into daytime hours and are not recommended.

You may be experiencing menopause. If you are younger than forty, menopause is not considered normal and is much less likely, but it is still possible. Abnormally early menopause is called “premature ovarian failure.”

You should discuss your symptoms with a doctor so he or she can confirm your condition and can discuss treatment that is available to reduce your hot flashes.

You should discuss this symptom with your doctor.

Common causes of a need to urinate at night include treatment with diuretics such as hydrochlorothiazide, furosemide (Lasix), and others, medicines that cause fluid retention such as rosiglitazone (Avandia), diltiazem (Cardizem) and others, leg swelling (edema), congestive heart failure, prostate enlargement, diabetes, bladder infections, and an overactive bladder.

There are several ways that your breathing can be interrupted during the night. If your breathing has been interrupted because of an upper airway blockage, then you typically can recover your breath immediately upon awakening. Respiratory discomfort that is caused by another problem may take slightly longer to resolve.

Please pick the statement that most closely describes your symptoms upon awakening:

I must sit upright to breathe and recovery may take minutes.

I snore or choke on awakening but catch my breath right away.

You are describing a pattern of awakening that is suggestive for the condition, “obstructive sleep apnea.”

This condition results when your airway tissues collapse together to close your airway as you enter deep stages of sleep. A drop in your oxygen results since you are not breathing effectively and this shortage of oxygen creates an alarm signal in your brain (a rush of adrenaline). You are awakened by the rush of adrenaline and your airway quickly reopens.

Obstructive sleep apnea is a dangerous condition when it is not treated. Repeated drops in your oxygen supply may result in heart failure. Persistent elevation of your body’s adrenaline hormones may cause hypertension (high blood pressure).

Your symptoms suggest a heart or lung problem. You should discuss your symptoms with a doctor as soon as possible.

Common causes of repeated awakenings with breathing distress include congestive heart failure, asthma, and occasionally, coronary artery disease (angina) or gastroesophageal reflux disease (GERD, acid reflux).

You should address your chest symptoms with a physician before pursuing other evaluation for your sleeping difficulties.

Your most bothersome problem is that you can’t easily get to sleep when you first go to bed. This type of insomnia is known as “initial insomnia.”

Sometimes a person is prevented from falling asleep by physical symptoms that may begin after lying down in bed. Physical symptoms can suggest a specific medical problem that may be the cause of your insomnia.

Are you kept awake by a recurring cough, pain in your chest, shortness of breath, or wheezing?

Yes, I have bothersome chest symptoms.

No, I do not have these chest symptoms.

Another symptom that can keep people from falling asleep easily is discomfort in the feet or legs. Discomfort could include burning or aching pain, cramps, or a need to keep the legs in constant motion due to a restless feeling in the legs.

Do you have discomfort of any kind in your feet or legs?

Yes, my feet or legs are uncomfortable.

No, my feet and legs don’t bother me.

You are not having pain or symptoms in your chest and you are not having pain in your legs or feet.

Are you kept awake by pain anywhere other than your chest, legs, or feet?

Yes, I do have pain that keeps me awake.

No, I am not kept awake by pain.

Pain commonly keeps people awake, and medicine that can reduce your pain may help you sleep better. Some pain medicines that are taken during the day can wear off during the night.

It is common for a variety of painful conditions to worsen at night. This may result in part due to an increased accumulation of fluid in joints, vertebral disks, and spaces within the skeletal system such as “bursa” spaces and compartments through which tendons pass.

Examples of conditions that can cause increased symptoms at night include

  • back pain from vertebral disk disease
  • carpal tunnel syndrome
  • bursitis in the shoulder or elsewhere.

You should discuss your pain with your doctor, to see if this symptom can be relieved. You should not pursue other evaluation or treatment for your insomnia until your pain problem is addressed.

It is common for emotional stress to keep a person awake at night. Insomnia can also be a symptom of depression.

Even if you cannot identify a recent change in your life stress or mood, emotional strain may be contributing to your sleeplessness.

Are you preoccupied by life stress at night, or do you feel anxious or depressed?

Yes, I am worried, anxious, or depressed.

No, I am not worried, anxious, or depressed.

You may still be able to adjust your daily routine to help yourself fall asleep more readily. The next several questions will review this possibility.

In order for you to get to sleep, your brain has to first become less intellectually busy.

Do you read in bed, watch television from bed, solve problems while you wait for sleep, or engage in “pillow” conversations?

Yes, this describes my situation.

No, this does not describe my situation.

You are doing just the right thing by avoiding these activities in bed. Your good habits will help your body to associate your bed with sleeping, not with other activities.

Do you exercise on most days?

Yes, I exercise on most days.

No, I do not exercise on most days.

Your body will need more sleep and will welcome sleep more easily if you develop a more active lifestyle during the day. Exercise should be completed at least four or five hours prior to the time you retire to bed, since immediately after exercise it is common for a person to feel wakeful.

Exercise during the day is a wonderful habit, and when it is timed right, it contributes to a very sound night’s sleep. However, after vigorous exercise your body produces a rush of adrenaline that can keep you wakeful for several hours.

Is it common for you to exercise within four or five hours of your bedtime?

Yes, this is true for me.

No, I do not exercise four or five hours before bedtime.

You have excellent exercise habits, and this is probably not your source of sleep problems.

Let’s check on another problematic habit:

Do you take daytime naps?

Yes, I take naps.

No, I do not nap during the day.

Excellent. Daytime naps can make nighttime insomnia worse.

Do you maintain a regular bedtime, and does your bedtime follow an adequate evening meal?

Yes, I do.

No, I do not.

We are all creatures of habit, and we enjoy our comforts. If you go to bed hungry or if you alter your bedtime schedule, then you may be expecting your body to adjust too much from one day to another. You will probably get to sleep more easily if you maintain a more regular bedtime, or if you avoid going to bed hungry or overfed.

Almost done!

Click here to continue.

You have reported excellent personal habits relating to your sleep routine, also known as “sleep hygiene.” The next thing we should explore is whether your bedroom is a comfortable place to get to sleep.

Is your bedroom a noisy place, due to sounds from inside or outside the room?

Yes, my bedroom is noisy.

No, my bedroom is not noisy.

Light stimulates the brain and can keep you awake. The first thing you should do to address your insomnia is to reduce the light that enters your room. Commonly this requires the installation of window blinds.

Last question!

That sounds good.

Is your room an uncomfortable temperature, or does it have any bad smells?

Yes, this describes my situation.

You have not identified any significant problems with your sleep habits or your sleep environs that provide an obvious explanation for your insomnia. You may find it helpful to speak to your doctor about your insomnia symptoms, so that your doctor can consider testing your thyroid and blood chemistry if your medical history suggests a specific medical problem that could be the cause.

Many people with insomnia find it very helpful to obtain training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order. Relaxation exercises before bed can greatly enhance your ability to get a full night’s sleep.

Most people do not require medications to assist with sleep. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from a doctor’s prescription for a sleep aid to use for a short term (typically less than two weeks).

You are reporting a problem with either the temperature or an odor in your bedroom.

Since you need to be completely comfortable in order to get to sleep, correcting the problems in your room environment will be important steps toward an improved night’s sleep.

Last question!

The brain is programmed to arouse you when you hear any distinct noise. The best way to improve your sleep may be to decide upon a way to reduce the noise in your sleeping environment. Options might include

  • changing to a different room
  • insulating your room from noise
  • using a device that can drown out interesting noises with a monotonous sound, such as a fan or a radio that is tuned to static between stations.

Daytime naps can put you in a vicious cycle of sleeplessness. The body only needs a certain amount of sleep. If you nap during the day, you will probably be too wakeful in the evening for your body to easily get to sleep or stay asleep. Your sleep is likely to improve if you eliminate daytime naps.

You should keep up your exercise, but you are likely to sleep better if you adjust the timing of your exercise. Complete your vigorous exercise at least four hours prior to the time that you retire to bed.

You should reduce the mental stimulation that you engage in after you have put yourself to bed. This means discontinuing bedtime television, reading, and conversation.

If you are unable to sleep and you decide to read or to watch television, remove yourself from your bed and go to a different room. You need to condition your body to associate your bed with sleeping, not with other activities.

It is appropriate to discuss your symptoms of anxiety or depression with your doctor. Your doctor can evaluate you for medical conditions that can result in both depression or anxiety and insomnia, such as a thyroid abnormality. Your sleep is likely to improve if you receive treatment for depression or anxiety. If your stress is due to difficulties in your home, family, or work life, your sleep is likely to improve as you identify ways to reduce your stress or manage your stress more effectively. In addition to addressing your mental health needs, you should consider these strategies to improve your sleep

  • Seek training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order.
  • Avoid going to bed hungry.
  • Avoid daytime naps, and sleep only as much as you require.
  • Maintain a regular bedtime.
  • Establish an active daytime lifestyle that allows you to go to bed ready for rest. It is preferable that you complete any vigorous exercise four or five hours prior to your bedtime.
  • Reduce the mental stimulation that you experience after you have put yourself to bed. This means discontinuing bedtime television, reading, and conversation.
  • Reduce noise stimulation within your bedroom. This may require the use of a device that can drown out interesting noises with a monotonous sound, such as a fan or a radio that is tuned to static between stations.

Most people who are reacting to emotional stress do not require medications to assist with sleep and find relaxation techniques or therapy sessions to assist in stress management most helpful. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from treatment by a therapist or prescription treatment for your depression or anxiety. Some depression treatments are particularly helpful at assisting with insomnia. If you decide with your physician that a prescription sleep aid (“sleeping pill”) may be helpful and it is one that is not also an antidepressant medicine, it is appropriate to use the sleep aid only for a short term (typically less than two weeks). Some doctors recommend sleeping pills during the time that a prescribed anti-depressant medicine has not yet had its full effect. Over-the-counter sleep treatments can cause symptoms that persist into daytime hours and are not recommended.

You have identified that your feet or legs are uncomfortable, and this may be what is keeping you awake at night. More information about your discomfort may help us to identify the most likely cause.

Which statement most closely describes your symptom?

I burn, ache, or cramp in one or both legs or feet.

My legs or feet kick, move back and forth, or feel “restless.”

It is possible that you have the condition, “restless legs syndrome.”

This problem is not dangerous but it can result in inadequate sleep.

Restless legs syndrome can be caused by some medications (most commonly, psychiatric medicines). It can also be a symptom of iron deficiency. Most often, it is unexplained.

If your doctor feels that restless legs syndrome is an appropriate diagnosis, there are several different medications that may relieve your symptoms.

Leg and foot pain at night is common. It can be a symptom of a serious medical condition, so you should have this symptom evaluated by your doctor.

The most common problem that results in leg pain at night is leg cramps. Leg cramps can be caused by some medical conditions or medicines, but very commonly they are the result of inadequate stretching of the calf muscles during the day.

The most common problem that results in foot pain at night is “peripheral neuropathy.” Peripheral neuropathy is caused by nerve injury and is common in diabetics.

A worrisome problem that results in foot pain at night is peripheral vascular disease. Foot pain in this instance is related to the symptom of “claudication,” which is pain in the lower limb that occurs with exercise. Foot pain with elevation of the foot, or buttock, leg or foot pain with exercise can be caused by inadequate blood flow to the lower limb due to an artery blockage.

It is also possible for pain in the legs or feet to be caused by a condition known as “restless legs syndrome.” Medications are available to reduce symptoms of restless legs syndrome, if this condition is identified.

Your nighttime chest symptoms could arise from a heart or lung problem. You should discuss your symptoms with a doctor as soon as possible.

If you have chest pain at night, this symptom may be a form of angina, which is chest pain or tightness that occurs when an area of your heart is receiving inadequate blood flow. Occasionally people with heart disease have increased symptoms several hours after their evening meal, when blood flow is diverted to the digestive organs. This would fit with chest symptoms at bedtime. Symptoms of chest pain with exercise, sweating, or left arm, shoulder or neck symptoms such as pain, numbness or tingling can also be symptoms of heart disease. Delaying medical care is very dangerous when heart disease may be taking place.

Chest pain may also be a sign of gastroesophageal reflux disease (GERD, acid reflux). Acid reflux causes a burning or aching pain behind the breastbone and commonly occurs when you lie down.

Shortness of breath or cough upon lying down may be caused by allergic asthma (especially due to dust mite allergy with exposure to allergens in your bedding), other respiratory conditions, acid reflux (when refluxed acid results in irritation of the airways) and congestive heart failure. Congestive heart failure commonly causes increased symptoms after lying flat because fluid that has accumulated in the legs returns to the bloodstream and heart when the legs are elevated.

You should address your chest symptoms with a physician before pursuing other evaluation for your sleeping difficulties.

It is easy for most people to understand how stimulating substances like nicotine may interfere with sleeping. Insomnia can also result when a nervous system “depressant” (such as alcohol) wears off. During your exposure to alcohol or another nervous system depressant, the brain produces extra chemicals that have stimulating effects in order to help you to compensate. When your alcohol (or any other “depressing” substance) wears off, your natural brain stimulants are still active. Insomnia is one of the most common symptoms of alcohol withdrawal, and it can occur even with modest regular alcohol consumption.

You should abandon habits that are not healthful. Your sleep will benefit and so will your overall health.

You have identified a recent increase in your emotional stress as a possible source of your insomnia. Since your stress has been severe enough to interfere with your sleep, it is appropriate to discuss your symptoms with your doctor. Your sleep is likely to improve as you identify ways to reduce your stress or manage your stress more effectively. In addition to addressing your mental health needs, you should consider these strategies to improve your sleep

  • Avoid alcohol and smoking, especially in the evening.
  • Seek training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order.
  • Avoid going to bed hungry.
  • Avoid daytime naps, and sleep only as much as you require.
  • Maintain a regular bedtime.
  • Establish an active daytime lifestyle that allows you to go to bed ready for rest. It is preferable that you complete any vigorous exercise four or five hours prior to your bedtime.
  • Reduce the mental stimulation that you experience after you have put yourself to bed. This means discontinuing bedtime television, reading, and conversation.
  • Reduce noise stimulation within your bedroom. This may require the use of a device that can drown out interesting noises with a monotonous sound, such as a fan or a radio that is tuned to static between stations.

Most people who are reacting to emotional stress do not require medications to assist with sleep and find relaxation techniques or therapy sessions to assist in stress management most helpful. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from a doctor’s prescription for a sleep aid to use for a short term (typically less than two weeks). Over-the-counter sleep treatments can cause symptoms that persist into daytime hours and are not recommended.

You have identified a change in your habits or sleep environment as a possible source of your insomnia. Most people are able to adjust to changes in their work and sleep schedule as time passes. Your strategies to improve your sleep should address the change in your sleep environment, and you should also consider these strategies

  • Avoid alcohol and smoking, especially in the evening.
  • Avoid going to bed hungry.
  • Avoid daytime naps, and sleep only as much as you require.
  • Maintain a regular bedtime.
  • Establish an active daytime lifestyle that allows you to go to bed ready for rest. It is preferable that you complete any vigorous exercise four or five hours prior to your bedtime.
  • Reduce the mental stimulation that you experience after you have put yourself to bed. This means discontinuing bedtime television, reading, and conversation.
  • Reduce noise stimulation within your bedroom. This may require the use of a device that can drown out interesting noises with a monotonous sound, such as a fan or a radio that is tuned to static between stations.
  • Seek training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order.

Most people who have had a change in their sleep environment do not require medications to assist with sleep. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from a doctor’s prescription for a sleep aid to use for a short term (typically less than two weeks). Over-the-counter sleep treatments can cause symptoms that persist into daytime hours and are not recommended.

Since your recent change in medicines is a likely cause of your insomnia, you should discuss this possibility with your doctor as the first step in your evaluation.

Please do not make a change in your use of a prescription medication without first consulting your doctor.

Caffeine can stay in your system for many hours after you consume a caffeinated beverage, and it is one of the most common causes of insomnia. Before you try other strategies to reduce your insomnia, it would be practical for you to eliminate caffeine outside of morning hours.

Click here to continue with the Insomnia Guide

New insomnia can be a side effect of a medicine that stimulates your central nervous system, although not all people will experience this side effect. Please review the following list of medicines that can stimulate the central nervous system:

  • decongestants such as pseudoephedrine or phenylephrine (Sudafed, Sudafed PE and other brands)
  • drugs for smoking cessation such as nicotine or bupropion (Zyban, Wellbutrin)
  • antidepressant drugs
  • asthma medicine (inhalers, albuterol, or theophylline)
  • prednisone
  • beta-blocker medications such as atenolol (Tenormin), propranolol (Inderal), metoprolol (Toprol) or others
  • clonidine (Catapres), most commonly prescribed for blood pressure
  • thyroid replacement
  • anxiety medicine
  • diet or weight loss pills
  • medicine for attention deficit disorder such as methylphenidate (Ritalin, Methylin, Metadate, Concerta), atomoxetine (Strattera) and others
  • medicine for narcolepsy such as drugs containing dextroamphetamine (Dexedrine, Adderall), modafinil (Provigil), and others
  • migraine medication
  • medicines for Parkinson’s disease.

Are you taking any medications from these categories?

Yes, a medicine change may be the cause of my insomnia.

No, I don’t take any of these medicines.

New insomnia can be a side effect of a medicine that stimulates your central nervous system, although not all people will experience this side effect. Please review the following list of medicines that can stimulate the central nervous system:

  • decongestants such as pseudoephedrine or phenylephrine (Sudafed, Sudafed PE and other brands)
  • drugs for smoking cessation such as nicotine or bupropion (Zyban, Wellbutrin)
  • antidepressant drugs
  • asthma medicine (inhalers, albuterol, or theophylline)
  • prednisone
  • beta-blocker medications such as atenolol (Tenormin), propranolol (Inderal), metoprolol (Toprol) or others
  • clonidine (Catapres), most commonly prescribed for blood pressure
  • thyroid replacement
  • anxiety medicine
  • diet or weight loss pills
  • medicine for attention deficit disorder such as methylphenidate (Ritalin, Methylin, Metadate, Concerta), atomoxetine (Strattera) and others
  • medicine for narcolepsy such as drugs containing dextroamphetamine (Dexedrine, Adderall), modafinil (Provigil), and others
  • migraine medication
  • medicines for Parkinson’s disease.

Are you taking any medications from these categories?

Yes, a medicine change may be the cause of my insomnia.

No, I don’t take any of these medicines.

The next thing we should explore is whether the morning environment in your bedroom is a comfortable place for you to remain asleep.

Does your bedroom become noisy in the morning, due to sounds from inside or outside of the room?

Yes, that’s a problem.

No, this does not describe my situation.

The next thing we should explore is whether your bedroom is a comfortable place to get to sleep.

Is your bedroom a noisy place, due to sounds from inside or outside the room?

Yes, my bedroom is noisy.

No, my bedroom is not noisy.

Okay. Depending on your circumstances, you might be able to keep things quite inside and outside your bedroom. If not, consider trying some comfortable ear plugs.

We hope this guide was helpful.

You may find it helpful to speak to your doctor about your insomnia symptoms, so that your doctor can consider testing your thyroid and blood chemistry if your medical history suggests a specific medical problem that could be the cause.

Many people with insomnia find it very helpful to obtain training in relaxation or “biofeedback” techniques, such as tightening and relaxing each of your muscles in a planned order. Relaxation exercises before bed can greatly enhance your ability to get a full night’s sleep.

Most people do not require medications to assist with sleep. If your sleep problems do not respond quickly to simple strategies to improve your sleep, you may obtain relief from a doctor’s prescription for a sleep aid to use for a short term (typically less than two weeks).

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