Items 1 through 4 are called normal sleep hygiene and should be done by everyone.

1. Establish a daily sleep/wake schedule.  This means keeping a consistent time each day for waking up the morning and going to bed each night.  Try to stay within 30-60 minutes of these times every day.  This includes through the weekend, holidays, and vacations.  In general allow AT LEAST 7 -8 hours of sleep each night.  As we age, we need less sleep, so someone in his eighties may need only 6 1/2 hours, while teenagers may well need 9-10 hours.

This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.

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2. Be careful with naps.  It's okay in general to take a short nap after lunch, a siesta, but avoid a long nap.  If you can't do this on your own, then set an alarm for a brief 10-15 minute nap.  If you have trouble falling asleep at night when you have napped earlier during the day, then eliminate the nap.  Just lie down and rest for 10-15 minutes instead during the day.  If you are the type who "never learned to rest" then, LEARN.  The relaxing response can be taught at any age.

3. Be careful with caffeine and pseudoephedrine, both of which promote alertness.  Caffeine lasts 6 hours.  If you go to sleep at night at 11 pm, then don't drink any caffeine any later than 3 pm.  Pseudoephedrine is in a lot of over the counter sinus or cold medicines-such as Sudafed, or Tylenol Sinus.  Pseudoephedrine is also the “D” appended to antihistamines such as “Allegra D,” or “Claritin D.”

4. Regular physical exercise promotes sleeping well.  The American Heart Association recommends that every body exercise aerobically for 20-30 minutes 3-4 times a week to decrease the risk of atherosclerosis.  As a physician I rarely see patients who do manual labor-carpenters, maids-who have trouble sleeping.  Exercise promotes the relaxing response.  A warning here is that some persons get too jived up after exercise to go to sleep.  They should exercise earlier during the day.  Exercise also induces endorphins, brain neurochemicals that reduce pain and promote calming.

5. A low volume ofa high calorie carbohydrate just before bedtime promotes sleep.  I'm talking about something like the proverbial "warm glass of milk."  This has been studied scientifically and shown to work.  You have to be careful here with the calories and cholesterol.

6. It's okay to get out of bed and go to another room for awhile, if you can't fall asleep when you first try.  Then you may read , preferably something not too interesting , technical, or work related, for 10-15 minutes.  However, watching TV or doing housework are not good options.  They're too stimulating.

7. Home remedies, vitamins, food supplements, and over the counter sleeping pills don't usually work for long term sleeping problems.  Therefore avoid them.  This includes Benadryl which is in Tylenol PM.  Melatonin is a drug that may work for a subset of patients with insomnia.  Unfortunately, it doesn't work for everyone.  A dose of 3-12 mg of melatonin may be tried.

8. Ambien is a class 4 narcotic, hypnotic sleeping pill that has been approved for chronic use.  Some patients are drowsy after using it and may be up at night and perform automatic funtctions, like raiding the refrigerator or wreck their car in the morning driving.  Other hypnotics are Restoril or Dalmane.  Rozerem is a non narcotic drug that works on the melatonin brain stem system.

9. Alcohol and minor tranquilizers (the Benzodiazepine drugs-Valium, Xanax, Ativan)-don't work that well either because they don't last all night and are not good long term options.

10. The majority of patients who have chronic sleeping problems also have pschological reactions or conditions that interfere with sleep.  Work directed toward resolving conflicts (psychotherapy) should be helpful.  Sleep lab information states that half of patients in America with insomnia are anxious and a quarter of them are depressed.  These are the most common causes of trouble sleeping.

11. The national sleep association has recommended that doctors first educate patients regarding Cognitive Behavioural Therapy (CBT) for insomnia before giving drugs.  CBT is a skill that can be learned from 6-8 visits with a psychologist, books on the subject, or by YouTube videos on: CBT and insomnia.  Watch the videos and learn.

12. The older antidepressant medications are, in general, safe for chronic sleep disorders.  Examples here would be: Elavil(amitriptyline), Desyrel (trazodone), Tofranil, or Pamelor.  All of these drugs have a sedating quality which will allow normal physiological sleep.

They are not addictive or habituating.  They commonly have mild side effects of a dry mouth which improves with therapy.  These are the drugs that may be used for long term sleep disorders.  Trazodone comes as a 50 mg tablet and this works well for the majority of patients with trouble sleeping.

However, if this dose is too high the patient should break it in half and take 25 mg.  A maximum of 150 mg/night may be used.  If the patient doesn't sleep all night on 50 mg then he should increase the dose by 25 mg /night per week until he sleeps all night.

The same approach may be used with amitriptyline where the dose may be started at 10 mg and can be just adjusted upward by 10 mg/night to about 75 mg until the patient sleeps all night. 

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All the best.

Britt Talley Daniel MD