Insomnia and difficulty sleeping: causes, red flags and when to seek help

The NHS says you have insomnia if you regularly find it hard to go to sleep, wake up several times during the night, lie awake at night, wake up early and cannot go back to sleep, still feel tired after waking, find it hard to nap in the day even though you are tired, feel tired and irritable, or find it difficult to concentrate. It notes that everyone needs different amounts of sleep and that you probably do not get enough if you are constantly tired during the day.

The pattern matters. Trouble getting off to sleep is often tied to worry or an overactive mind. Waking in the small hours and being unable to return to sleep is classically linked to low mood. Waking repeatedly with unrefreshing sleep points towards a physical disruptor, such as snoring and sleep apnoea, pain or night sweats.

The NHS lists the most common causes as stress, anxiety or depression, noise, a room that is too hot or cold, an uncomfortable bed, alcohol, caffeine or nicotine, illegal drugs like cocaine or ecstasy, jet lag and shift work. It also names mental health conditions such as schizophrenia or bipolar disorder, Alzheimer disease, Parkinson disease, restless legs syndrome, an overactive thyroid and menopause as conditions that can cause insomnia, and says many medicines can too.

The NHS says insomnia usually gets better by changing your sleeping habits. It advises going to bed only when sleepy, waking and getting up at the same time every day, relaxing for at least 1 hour before bed, making the bedroom dark and quiet, exercising regularly during the day and having a comfortable mattress, pillows and covers.

It advises not smoking or drinking alcohol, tea or coffee for at least 6 hours before bed, not eating a big meal late, not exercising within 4 hours of bedtime, avoiding screens right before bed because of blue light, not napping during the day, not driving when sleepy and not sleeping in after a bad night. That last point is counter-intuitive but important: a fixed wake time builds the sleep pressure that makes sleep come easily the next night.

Insomnia on its own is not an emergency, but some features suggest another condition needs attention. Loud snoring with witnessed pauses in breathing, choking at night and heavy sleepiness in the day suggest sleep apnoea, which the NHS lists as a cause of poor sleep and which can be investigated at a sleep clinic. Falling asleep suddenly anywhere suggests narcolepsy.

Persistent low mood, loss of interest, hopelessness or thoughts of self-harm alongside poor sleep need prompt help from a GP or, in a crisis, NHS 111 or 999. The NHS says insomnia affecting your daily life in a way that makes it hard to cope warrants a GP appointment. Drowsy driving is dangerous, and the NHS says not to drive when you feel sleepy.

Acting out dreams, violent movements in sleep, or new sleep disturbance with memory or movement changes are worth reporting to a doctor.

The NHS says a GP will try to find out what is causing your insomnia so you get the right treatment. Expect questions on your bedtime routine, time to fall asleep, awakenings, daytime function, caffeine and alcohol, medicines, mood and anxiety, snoring and pain. A sleep diary kept for two weeks, noting bed and wake times, naps and alcohol or caffeine, is very informative.

Examination is usually brief, focusing on weight, neck size, blood pressure and signs of thyroid disease. Blood tests may check thyroid function and iron, and a sleep study is arranged if apnoea or limb movements are suspected.

The NHS says sometimes you will be offered cognitive behavioural therapy (CBT), face-to-face with a therapist or through an online self-help programme, to help change the thoughts and behaviours that keep you from sleeping, and you may be referred to a sleep clinic if you have symptoms of another sleep disorder such as sleep apnoea.

It says GPs now rarely prescribe sleeping pills because they can have serious side effects and you can become dependent on them; they are prescribed only for a few days, or weeks at the most, if insomnia is very bad and other treatments have not worked. It also says pharmacy sleep aids containing ingredients such as valerian, lavender or an antihistamine cannot cure insomnia but may help for 1 to 2 weeks and should not be taken for longer, and may cause drowsiness. Check with a doctor before taking anything.