Sleep is important for health and wellbeing. Yet, adequate sleep is often under-attained. About 30% of adults have some insomnia symptoms. Seventeen percent of older men and 9% of older women have sleep apnea. Fortunately, there are a variety of methods — some not well known — to address sleep problems.
Standing in the way, sleep is culturally undervalued. We provide and receive too little sleep education. Often, complaints of lack of sleep are met with, “Join the club,” or “Have some coffee,” or “Take a nap.”
You won’t hear that from me. If you have sleep trouble, I want to get you some help. If you’re not feeling refreshed by your sleep, don’t belittle it, take it seriously. It doesn’t need to be “normal,” and it shouldn’t be a badge of honor. There’s a lot more you can do about it than you probably know.
I’ve spent the past decade or so learning about sleep and, unfortunately, its disorders. I’ve had three of them — chronic insomnia, sleep apnea, and sleep myoclonus, a sleep movement disorder that is not restless leg syndrome or periodic limb movement or seizures.
Much of the assistance I’ve found for these can be helpful for sleep in general. This post is a round up of everything I’ve learned, much of it by linking to other posts and sources. I will update this post as I learn more.
Nothing in this post is intended to be a replacement for consulting a medical professional for whatever sleep issue you’re having. Also, nothing in this post is necessarily a magic solution to all your sleep problems. If something works for you, great! If it doesn’t, don’t do it. Move on to something else. Plus, there are undoubtedly things that could work for you that aren’t included below, as I haven’t learned and tried everything.
Sleep Apnea, in Brief
I’ve already written a lot about sleep apnea and treatment for it. I won’t repeat myself. If you suspect you have it, go read my prior writing (start here). It is treatable, and you will feel better having treated it.
Insomnia, in Brief
Insomnia is not just “difficulty sleeping” — that is, it’s not one thing. There are different kinds, and the differences matter. Read about them here. Below, I will use terms and concepts found at that link.
If your insomnia is secondary to another condition, it’s essential to treat that other condition. You can’t solve insomnia directly if it is not the source of the problem. This is why it’s important to talk to a clinician about your sleep difficulties.
If you have primary insomnia (no underlying cause), cognitive behavioral therapy (CBT-I) is the best, known approach. It’s worth the effort and has no side effects or issues of dependency. I’ve written many posts on insomnia and about CBT-I here. I won’t repeat myself, so I’m moving on.
(If you’re thinking, “Wait, aren’t you going to talk about melatonin and other medications for sleep,” yes, yes I am, further below.)
Probably almost everyone could benefit from better sleep hygiene. Google it and you’ll find the customary advice (e.g., from the CDC). But, there’s more to good sleep hygiene than you’ll easily find. None of it has negative side effects. It can’t harm you.
To enhance sleep hygiene, here are some additional resources I learned from:
- Huberman Lab Toolkit for Sleep — All the basic points in it are excellent. If you want them and more in audio form, listen to this. I differ a bit with some of the specific recommendations (e.g., I did not find the Reveri app helpful, and I have more to say about supplements below). While you’re on the site or in your podcast app, do yourself a favor and check out all of Huberman’s podcasts on sleep. Yes, it’s a lot to listen to. But they’re so good, as are his episodes on other topics. You will learn a ton.
- Listen to Matthew Walker’s podcast and/or read his book.
- One trick, implied if not mentioned by Drs. Huberman or Walker, is to heat up your body externally before bed, even in the summer (e.g., hot shower followed by putting on more clothes than are necessary, which are then remove at bedtime). If you consume the content of Drs. Huberman or Walker, you’ll learn why this is helpful, but in a nutshell, it shuts down your body’s internal efforts to keep you warm. This actually speeds up the dropping of your internal temperature, which is necessary for sleep. The point is not to be externally overheated at bedtime and in bed, but before bedtime.
- Do not fear sleeping separately from your partner. Partners wake each other up. If you and/or your partner are struggling with sleep, sleeping separately, even if temporarily, can help. It’s OK. Lots of people do it, and their relationships are fine.
Relaxation Is Not Optional
I don’t believe there is anything you can do safely (e.g., putting aside use of medications or other substances to dangerous levels) that will put you to sleep if you don’t calm your mind. Put another way, relaxation is required. Your restless mind can override all the good sleep hygiene and safe, yet sleep inducing, substance/medication use.
Also, if you’re able to stay relaxed you may actually get more sleep than you think. I once had an EEG done during which I was supposed to fall asleep. It was a 45 minute test. I was tired and relaxed, but felt aware of every minute of it. Nevertheless, the tech said he recorded stage 1 and stage 2 sleep. He also said it’s very common for patients to report being awake during that test when they actually achieved light sleep. While we certainly need more than light sleep to feel optimally refreshed, light sleep is not no sleep. Getting at least that may be possible when things aren’t going well, but only if you’re relaxed.
A lot of sleep hygiene lists suggest that if you can’t sleep, you should leave your bed and go elsewhere to read or engage in some other relaxing activity (other than watching a screen, which crushes your melatonin, about which more below). In part for the reason just described, I don’t subscribe to this approach. If I leave my bed, I am definitely not going to sleep — I find leaving and coming back disruptive. Instead, I stay in bed, with a calm mind. If needed, I find something soothing to listen to. This works for me. Your mileage may vary. The point is: don’t be a slave to advice. Try it, and discard it if it isn’t helpful.
If you have trouble quieting your mind, whether in bed or elsewhere, and whether at the beginning or middle of the night, there are lots of resources to help. Here’s a list of things I’ve tried and tend to rotate through:
- 20 Best Guided Sleep Meditations To Help With Insomnia from Lifehack — Many are cheesy. Try them and see what works for you. Note that you don’t have to use the YouTube versions. You can find lots of these, or similar, on Spotify, for example.
- Sleep With Me podcast — Some episodes are very good (the one on making a salad is hilarious, but in a soothing way). Others don’t appeal to me. Overall, the concept of this podcast is great, even if imperfect in execution. Listen to a few to see what I mean.
- Non-sleep deep rest, e.g., this track — Search the term or NSDR and you’ll find lots more.
- Michael Sealey — Look for him on YouTube or Spotify. I really like him.
- Headspace — Most people know about Headspace as a meditation app. And for that, I think it’s a fine way to start. After some dozens of sessions with it for that, I got a bit tired of it. It seemed a little shallow, frankly, particularly compared to the suggestion in the next bullet. However, Headspace has some very good “Sleepcasts.” These are soothingly narrated vignettes, just engaging enough to take your mind off your other thoughts, but not enough to keep you up. I have fallen asleep to many. For this and some other sleep-related content, I like the app. (I’ve heard Calm is similar, but not used it.)
- Waking Up, by Sam Harris — I’m no meditation guru, but to my novice ear, this feels much more like the real deal. The content of the app goes very deep into the purpose of meditation. It’s not just for relaxation, but to understand the true nature of the mind and reality.
- Any music that is calming for you — For me, its often minimalist. I hunt on Spotify and find what seems to put me in a sleepy mood.
- Audio books — There are few nights I do not listen to one in my near final approach to sleep. I prefer this to reading by eye in the last 30-60 minutes before sleep. I want my eyes closed, the room completely dark.
As you can tell from above, there’s some overlap between relaxing audible content and guided meditation. If memory serves, Sam Harris and Matthew Walker converse (in the Waking Up app) about how there is not good evidence that mediation helps with sleep. Consistent with this, I do not find the Waking Up app to be helpful at bedtime or in the night.
But I do find that the practice of meditation at another time of day to help me build some skills I use in the night to good purpose. Being able to focus my mind on my breath, to accept the passing of thoughts and emotions without getting wrapped up in them, to be able to more readily achieve a sense of peace is very helpful to me in the night. So, I do recommend the Waking Up app, or some other means to practice self calming or meditation if you have difficulty quieting your mind.
As you undoubtedly know, there is medication specifically intended for sleep and FDA approved as such. This includes Ambien, Lunesta, Belsomra, among others, and their generic equivalents. They’re not intended for long-term use for primary, chronic insomnia (see above for CBT-I).
In the US, you need someone to prescribe these anyway, so I don’t have to say that you should discuss these with a medical provider you trust before using them, but of course you should! Be sure to come to some agreement about how often you use the medication and at what dose. Just because you may get a 30 day supply with 5 refills doesn’t mean you should use it straight for the next 150 days. Talk about stopping use just as much as starting use. Talk about what to do if you feel you are becoming reliant on medication for sleep.
However, just because you should talk to your clinician of choice doesn’t mean you should not also do your own homework. As you’ll see at the above link and elsewhere, each of these medications has a different mechanism of action and half life (the duration until half of the meds are cleared from your system). In other words, not every one will be right for your exact issue. What’s good for helping you fall asleep may not be the same thing as helping you stay asleep. Assuming something like a 7AM wake up, what’s OK to take at 11PM is not the same thing as something you can safely take at 3AM. If you need something for returning to sleep at 3AM and you are prescribed Ambien, there’s a problem. Waking up at 7AM is going to be tough. It’s to your benefit to be aware of this.
You also probably know there are medications not originally intended as sleep aids that are prescribed and used as such. These include Trazodone and Benzodiazepines. And there are many other medications used for other purposes that also cause drowsiness (e.g., Gabapentin, Pregabalin, Baclofen, Levetiracetam, etc.). Very likely if you’re prescribed one of these it’s for something other than sleep, though it may be for something that is also disrupting your sleep, like a movement disorder or mental health diagnosis. That is, your insomnia is not primary, and these meds help treat the underlying condition while also helping you sleep.
About all these medications not originally intended for sleep I want to say just two things, one in general and one specific to Benzodiazepines.
In general, I recommend looking up the mechanism of action and half life of medications prescribed to you if they make you sleepy. You can Google these and usually find the answer relatively easily, with some exceptions. It’s very helpful to know why meds do what they do. For sleep, typically it’s because they play some role pertaining to GABA, serotonin, or melatonin. If you’re on multiple medications that hit the same system, you might want to discuss that with a medical professional. Is it too much? Is there a danger of receptor down-regulation with long term use?
The half life will help you know how long the medication could make you sleepy, though it’s just a rough guide, particularly because elimination of half or even 3/4ths of the medication (e.g., in two half lives) still means there’s a substantial amount left in your system. (I’ve taken medication with a 7 hour half life that makes me drowsy for a whole day.) Having said that, it can also happen that something that knocks you out initially won’t in a few weeks, as you adjust to it.
About Benzodiazepines, be careful. Developing a tolerance and needing more and more can happen. Getting off them can be difficult. I recommend reading the Ashton Manual to know what you’re getting into and what getting out of it might look like. (One critique of the Manual is that it does not consider the case for which one needs to taper off a Benzo but one still requires the therapeutic function it provides. This is not “swapping one dependency for another” in a bad sense. If you need medication for a condition, you need medication for a condition.) What I said about sleep medications above applies here too. If you are prescribed one, talk with a clinician about how often and long to use it. Talk about what to do if you feel you’re becoming dependent. Don’t increase your dose without discussing it with a medical professional.
Having said that, if you require a Benzo for a condition, try to avoid (or get help avoiding) being anxious about its use to the point of mentally harming yourself. It’s very easy to encounter horror stories about them, and that can be harmful to you if you need them. Anxiety about medication you need is not helpful. So long as you always use it within the bounds as agreed to with your health care provider, you are unlikely to have a significant problem.
Many people self-medicate for sleep with over-the-counter medications like Nyquil, Benadryl or their generic equivalents. Doing this to address a longstanding sleep issue is probably not in you best interest. Instead, discuss the problem with a clinician. Maybe there’s a more appropriate approach. Having said that, your health care provider may very well say what you’re doing is fine. But, why guess?
Alcohol and Other Drugs
You can read/listen to Drs. Huberman and Walker (or just search online) to learn why alcohol or other recreational drugs are generally not ideal for sleep, even if they make you sleepy. Typically they harm your sleep architecture — basically harming the quality of your sleep without you necessarily knowing it. Using these for sleep problems is just not an ideal approach.
Supplements (Beyond Melatonin)
In general, there is no strict, functional difference between prescription or over-the-counter medication (or recreational drugs) and supplements. They’re all just molecules that cause changes in the body. You can be helped or harmed by just about anything, depending on how it’s used. But, prescription and over-the-counter drugs are more tightly regulated for safety, and that is important. The supplements market is famously full of crap and quackery. Here are tips for finding more trustworthy products.
The same thing I said about prescription drugs regarding primary or secondary insomnia applies to supplements too. They’re not the best approach for primary, chronic insomnia (again, start with CBT-I). However, if you have acute and/or secondary insomnia, use of supplements is just as sensible as using prescription medications, if they work for you.
There are quite a few useful supplements for sleep. They’re not like “baby prescription drugs.” They can be powerful and do harm. Below, in rough order of increasing half life, is a list of ones with which I have some experience, with information on half life (HL) and mechanism of action (MOA),* if I could find it. Once again, I would encourage you to consult a medical provider before using any supplements.
Melatonin — HL: 20-50 minutes; MOA: It’s melatonin!
In contrast to the other supplements below, I have a lot to say about melatonin. Your body makes it naturally, though less of it as you age. It needs to rise for sleep. In addition to making you sleepy, it also helps cool you down, which helps for sleep too.
If you’ve read into the sleep hygiene links above, you’ve learned that light kills your melatonin, not just blue light, all light. So, dimming the lights and not looking at screens in the hours before bed can help. Not turning on lights in the middle of the night can also help. Don’t look at your phone! And if you must, keep it dim, and even turn it a bit to the side so you’re not looking squarely into the light. (There’s much more to the role of light for sleep. For that, scroll up to the sleep hygiene section and consume the content at the links to Huberman Lab.)
There’s a common misconception that melatonin will help you stay asleep. Nope. Supplementing with melatonin is only helpful for sleep onset (note the short half life). There’s also a popular belief that more is better. Again, no. Studies show that 3mg or less is best. More can actually harm sleep. Most formulations (at 5, 10, or more mg) are worse than useless. You can find lower mg formulations or split tablets.
L-Theanine — HL: 1 hour; MOA: increases GABA synthesis. From here downward, we get into supplements with half lives longer than melatonin. So, we begin to transition from things that help with sleep onset to those that help with sleep maintenance (staying asleep) for various lengths of time. For example, L-Theanine, with a half life of 1 hour, may help you stay asleep for something like 1-3 hours (your mileage may vary). This is the kind of time frame that could help you at 3AM if you need to wake at 7AM. Having said that, you can still use it at bedtime (and again in the middle of the night). You can use the same sort of logic for the following supplements.
Taurine — HL: 1.5 hours; MOA: GABA-A agonist.
L-Tryptophan — HL: 1.75 hours; MOA: used to make melatonin and serotonin.
5HTP — HL: 1.75 hours; MOA: used to make melatonin and serotonin. 5HTP is made from tryptophan and it crosses the blood brain barrier more readily than tryptophan. So, many prefer it to L-Tryptophan, myself included.
pharmaGABA (by Thorne) — HL: 5 hours; MOA: This is exogenous GABA.
Myo-Inositol — HL: 5-8 hours; MOA: increases serotonin density, whatever that means.
CBD — HL: 1-2 days; MOA: Seems not well understood. It wasn’t useful for me, but others like it. Here’s a New York Times article about use of CBD for insomnia.
Tart Cherry — HL: ???; MOA: Speculated to increase melatonin. Yes, this is fruit (or juice or extract in capsule form). All molecules are drugs, including fruit.
Magnesium Glycinate — There are many formulations of magnesium. I’m told that this one is most helpful for sleep. MOA: regulates melatonin production, increases GABA, is a GABA receptor agonist. I could not find HL information. Yes, you can get magnesium in your diet. Again, molecules are drugs, no matter their source.
Other things not on this list that can help in some cases — Depending on their condition, some people’s sleep is helped with vitamin and mineral supplementation (e.g., iron, B vitamins, electrolytes). While I use these for my condition, I don’t have a lot to say about them. To know if they’re right for you and in what quantities you need to get labs done, follow a health care provider’s recommendations based on those, and then retest to see if you’ve moved your levels to a more desirable place. You can also, of course, just experiment to some extent. But you could spend a lot of time not quite getting to the right place. Changes can take months to experience and if you’re under-dosing or not getting labs done, you won’t know what’s happening.
You’ll notice I’ve left out two things for everything above: dosage and how long it takes for a supplement (or med) to kick in. These are things you can Google. I actually don’t know the answer or what’s true for you or right for you. I’d only recommend that if you’re experimenting with things that can have strong effects, you start with lower doses. If you can split tablets, do that. If you can find capsules that are at the low end of what’s on the market, use those. You can always take two or three to get up to the higher doses suggested out there. Your health care provider may also advise you on dose. Likewise, experiment with timing of dose. If taking something right at bedtime means you wait 1.5 hours until sleep arrives, consider taking it a lot earlier. This advice applies to prescription medications too.
Let me state what I would hope would be obvious: Don’t take all of these at once! Apart from talking to a clinician about them, my recommendation would be to experiment with them individually and then, perhaps, in some combination of at most a few. Over time you’ll figure out which are best for you at what time and for what purpose. Keep in mind all that I said above: these are not durable solutions to primary, chronic insomnia (CBT-I is). But, these may be helpful for other purposes — when your sleeplessness is secondary to something else (even if just travel) or not chronic.
That’s it for now. I’ll add more as I learn. Happy sleeping!
* These were basic Google Searches done months ago, so I’m not providing links. I’m told by people who know better than I do that mechanism of action isn’t always well known. It’s sometimes theoretical or educated guesswork. Take what I’ve written with a grain of salt. Feel free to do your own searching on this as well. If you find I got it wrong, let me know.