Monday, June 11, 2018

Insomnia: A Dreamer's Nightmare

Sleep. We all want it but can never seem to get enough of it.

“I keep waking up in the middle of the night, what do you recommend for sleep?”
“I haven’t slept in three days, what can I take?”
“I have insomnia, what’s good for sleep?”

These are just some of the questions community pharmacists face every day, but are we clear on what insomnia is and what the options are?

What exactly is insomnia?1

We throw around the term insomnia all the time, but what is the clinical definition? To be diagnosed with insomnia, the following criteria must be met:
  • Dissatisfaction with sleep quality or quantity, this could be 1 or more of the following:
    • Difficulty in falling asleep (sleep latency) 
    • Difficulty staying asleep 
    • Early morning awakening without being able to return to sleep 
  • Sleep disturbance must cause functional impairment or distress 
  • It occurs at least 3 nights per week for at least 3 months 
  • It cannot be substance related (e.g. Medication or drug of abuse)

So, what can we recommend?

Over the counter pharmacotherapy is limited to antihistamines, namely, diphenhydramine (Nytol, Sleep-Eze, Unisom, ZzzQuil and any generics). The dosing ranges from 12.5 – 50 mg, optimally 50 mg, 30 to 60 minutes before bedtime. However, this is only a temporary solution and should only be used for a short, intermittent (less than 4 times weekly) basis.
Other pharmacotherapy measures require a prescription and include benzodiazepines and nonbenzodiazepine GABA agonists.

Natural Health Products
There are two common natural health products marketed for insomnia – melatonin and valerian.

Melatonin (N-acetyl-5-methoxytryptamine) has been reported to increase total sleep time, relieve or prevent daytime fatigue associated with jetlag, reduce sleep onset latency, help reset the body’s sleep-wake cycle and improve overall sleep quality. Although the absolute benefit of melatonin compared to placebo was less significant when compared to other pharmacological treatments, melatonin may still play a role due to it’s side effect profile.2

Valerian (Valeriana officinalis) has been reported to improve sleep quality but most of the studies had significant issues with methodology and numerous variations in dosing, preparation and length of treatment.

Clinical Tip: Always refer to a physician if any over-the-counter product is required for over 7 consecutive days.

Nonpharmacologic Therapy
Nonpharmacologic treatment is the first line option because it is a safe and effective alternative to pharmacologic therapy. This comprises of psychological and behavioural including stimulus control therapy, relaxation training and cognitive behavioural therapy (CBT). A combination of these techniques can be found below!

Image result for CLOCK insomniaTop 10 tips for battling insomnia1
  1. Avoid napping during the day
  2. Maintain a regular schedule – go to bed and get up at a consistent time every day (including weekends)
  3. Implement a winding down ritual before bed using relaxation techniques like stretching, taking a warm bath
  4. Use your bedroom only for sleep and sex. Avoid watching television and eating in the bedroom.
  5. Make your bedroom the most comfortable place to sleep by ensuring it’s an ambient temperature and cutting down on light and noise
  6. Pick a comfortable mattress and pillows!
  7. Exercise regularly (aim for the late afternoon and avoid 2 hours before bedtime)
  8. Avoid alcohol, caffeine, nicotine and eating heavy meals before bed
  9. Reduce your fluid intake before bed to avoid sleep disruption
  10. Try creating a sleep diary!

I hope you were able to gain some insight from my blog posts – I know I’ve learnt a lot but it’s time for me to hit the hay. Goodbye and good night rxBriefCase!


  1. Procyshyn, R., Barr, A., CTMA [Internet]. Ottawa (ON): Canadian Pharmacists Association; c2018 [updated 2017 06; cited 2018 06 07]. Insomnia. Available from Also available in paper copy from the publisher.
  2. Ferracioli-Oda, E., Qawasmi, A., & Bloch, M. H. (2013). Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders. PLoS ONE8(5), e63773.