How to Stay Asleep: Help for Middle-of-the-Night Awakenings
How to Stay Asleep: Help for Middle-of-the-Night Awakenings
By Beth Janes Posted 11-21-2018
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It’s 2:30 a.m. and you’re wide awake — but not by choice. You’re exhausted. You managed to fall asleep at a reasonable hour, but now you’re up and sleep just won’t come. Sound familiar?

When it comes to sleep trouble, an inability to fall asleep is hardly the only issue. In fact, for many people, drifting off at the beginning of the night is a breeze — the trouble starts a few hours later. For example, a recent Vital Plan survey found that about three-quarters of people said staying asleep was their biggest sleep problem, compared to only 40 percent who said they had difficulty falling asleep initially.

Aside from the frustration and fatigue, sleep disruptions like waking up in the middle of the night can be harmful to your health. In the short term, a reduction in both quality and quantity of sleep can increase stress and inflammation, as well as lead to emotional distress and mood issues, plus memory and cognitive problems, according to a paper in the journal Nature and Science of Sleep. Long-term problems that have been linked to sleep disruption include high blood pressure, metabolic and weight problems, heart disease, and colorectal cancer.

So what’s behind the nocturnal wakeups? It could be any number of issues, says Bill Rawls, M.D., medical director of Vital Plan. But to get to the bottom of them, it first helps to understand the basics of how we sleep.

The stages of sleep

“Most people have this idea that when your head hits the pillow, you’re supposed to go into a deep state of calm and not come out of it until morning,” says Dr. Rawls. “But that’s not the way it goes — sleep is extremely dynamic.”

During the night, you move in and out of four stages of sleep. The first two are considered light sleep — your body relaxes, and although your brain waves slow down, they continue to show some activity. That’s why it’s easiest to wake up during stages 1 and 2, and it’s when you’re more likely to. Light sleep also makes up the majority of a normal night’s sleep.

On the other hand, it’s more difficult to wake up during stage 3, called deep sleep, when your body and brain are most relaxed. The fourth stage, REM, stands for rapid-eye movement. During REM sleep, you dream and your brain activity looks similar to when you are awake, but your body stays temporarily paralyzed to keep you from acting out dreams. When you wake up from this type of sleep, you likely remember your dream clearly. All four stages are important for both physical and cognitive functioning and health.

“The first half of the night, you oscillate between non-REM and REM sleep, but with a predominance of non-REM sleep,” explains Dr. Rawls. “Then the second half of the night, you have more REM sleep. Going in and out of the sleep stages means there are a lot of opportunities to wake up and stay awake.”

In other words, stimuli — including external, like a too-hot room or loud noise, or internal, such as pain or the urge to urinate — could be enough to wake you from light sleep. What’s more, too much light sleep and not enough time in deep or REM sleep can also mean more chances you’ll wake up.

So the key to staying asleep is to both minimize the things that may rouse you, and also to make sure that if you do wake up briefly, you do what you can to make falling back asleep easier, Dr. Rawls says. Keep reading to learn about some of the most common stimuli that typically cause people to wake up in the middle of the night and what to do about it, followed by general tips for how to stay and get back to sleep.

9 top sleep disruptors + how to avoid them

1. Afternoon or evening caffeine

Even if you’re the type who can fall asleep easily after drinking coffee or black tea in the evening, caffeine can interfere with sleep, waking you up and making it harder to fall back asleep, Dr. Rawls says. That’s because if you’re tired enough in the evening, sleep pressure will eventually build so much that you’ll doze off, but as it starts to wane, you may move into lighter sleep states where you feel caffeine’s arousing effects.

One study in the Journal of Clinical Sleep Medicine found that having caffeine six hours before bedtime resulted in sleep disturbances that reduced the amount of sleep by one hour. So if you’re going to have a post-lunch latte or caffeinated tea, it’s best to enjoy it at more than six hours before you plan to hit the hay that night — and maybe even seven or eight, to play it safe.

2. Alcohol

While alcohol can make you drowsy initially and cause you to fall asleep quickly, booze also triggers a type of brain activity during sleep that usually only occurs when you’re awake, so it may cause you to sleep fitfully or wake up throughout the night. “Metabolites in alcohol also act as stimulants,” Dr. Rawls says, so you may wake up as your body metabolizes the contents of your cocktails.

Alcohol can also interfere with adenosine and other chemicals that help you stay asleep. And it causes more light sleep — the stage where you’re more likely to wake up, according to a paper from the National Institute on Alcohol Abuse and Alcoholism. Finally, alcohol (and caffeinated beverages, for that matter) can lead to the need to urinate more frequently during the night, which can also wake you up.

If you’re using alcohol as a sleep aid, stop — it’s more likely to backfire than to help you. But if you’d like to enjoy the occasional cocktail, that’s fine. Just stop after one or two, and ideally a few hours before you go to bed.

3. Your diet

Issues with diet can be trickier to determine, because foods’ effects on sleep vary from person to person, Dr. Rawls says. For some, a drop in blood sugar or even full-on hunger pangs caused by going hours without eating may wake them up, he says. You might also experience low blood sugar in the night if you’ve been eating a diet high in carbohydrates, because your body has gotten used to living with high levels of glucose and insulin.

If either of those scenarios sound like, or if you tend to eat earlier in the evening and have lighter meals, try eating a small snack before bed — like a banana — to see if it helps. And be sure your meals contain a mix of fiber, protein, and healthy fats, which digest slowly and keep you fuller longer.

But be careful — eating a large or heavy meal too close to bedtime can also wake you up. “It doesn’t help your sleep when your body is churning away, trying to digest all that food,” Dr. Rawls says. In fact, one study found that the more food (especially high-fat food) you eat close to bedtime, the more potentially negative effects on sleep, including what researchers call “wake after sleep onset” — or nighttime waking. So try to eat dinner a few hours before bed and limit nighttime snacking to small, easily digestible foods such as fruit.

4. Your body temperature

When you sleep, your body temperature drops slightly, and feeling too warm could trigger you to wake up when you move into a light sleep stage, Dr. Rawls says. Researchers have indeed found that “sleep maintenance insomnia” (another term for nighttime waking with the inability to get back to sleep) is related not with issues of circadian rhythm timing, but rather more with nighttime elevation of core body temperature, according to a paper in Sleep Medicine Reviews.

So if you wake up feeling warm, either turn down the thermostat at the start of the night or use only a light blanket or sheet. It may take some experimentation to figure out what works, Dr. Rawls says, adding that some people need more or fewer covers. In general, though, try to keep the room around 65 degrees, according to the National Sleep Foundation.

5. Light and sound

These are two additional external stimulants that could rouse you in the middle of the night. If neighborhood noise and lights seep into your bedroom, consider using a white-noise machine and blackout curtains, as well as a motion-activated night light versus one that stays on all the time.

Also, avoid watching TV and using your mobile phone or computer an hour or so before bed. They’re mentally stimulating, for starters, which means they’re waking up your brain. They also emit blue light that can make it more difficult to fall asleep, plus it might cause you to have less restful or more light sleep.

6. Stress and anxiety

If you’re stressed and worried during your waking hours, the physical effects of those emotions don’t necessarily switch off once you drift off. Stress activates the body’s hypothalamic-pituitary-adrenal axis (HPA axis) and nervous system, which release hormones and other chemicals associated with alertness and results in an overall state of hyperarousal, according to a paper in the journal Experimental Neurobiology. That can interfere with normal sleep patterns, including triggering nighttime waking and an inability to get back to sleep. In fact, a quarter of people with anxiety suffer from this type of middle-of-the-night sleeplessness, reports one study.

In addition to lifestyle factors that help you manage stress (exercise, a healthy diet, etc.), taking certain herbs during the day can help balance stress hormones and calm the body, helping you get back on track at night, Dr. Rawls says. One he recommends is ashwagandha, which has strong supporting research.

One study, for example, revealed that participants who took ashwagandha for 60 days had lower levels of the stress hormone cortisol, and they scored lower on stress-assessment tests than those taking a placebo. Additional research has linked the herb to more normal and restful sleep. Two others herbs Dr. Rawls recommends for balancing stress are Chinese tree bark and l-theanine (from green tea).

7. Joint pain and chronic pain

Pain can easily disturb sleep and make it harder to get back to sleep if you wake up. Up to 80 percent of people with arthritis suffer from sleep issues, according to the Arthritis Foundation. And one study found that nearly half of those with chronic pain suffered from a sleep disorder, while more than a quarter were diagnosed with clinical insomnia. Unfortunately, this can lead to a vicious cycle: A lack of sleep can then make pain and other related symptoms worse and vice versa.

The good news: Research suggests that when you manage either pain or sleep effectively, symptoms of both improve, according to the journal Pain Research and Treatment. So be sure to take care of and protect your joints, and take steps to restore health and manage chronic illness that causes pain.

But those aren’t overnight solutions, so in the meantime, you might consider trying full-spectrum CBD oil (short for cannabidiol) for both acute pain and sleep troubles, if it’s available in your state, says Dr. Rawls. The non-psychoactive phytochemicals from hemp plants, CBD may be effective for both arthritis and other pain by reducing inflammation and acting on pain perception pathways, research suggests, and it’s been linked to improved sleep.

8. Factors related to aging

As people age, sleep patterns naturally change and tend to include more light-stage and fragmented sleep, according to a paper in the Handbook of Clinical Neurology, which notes that 40 to 50 percent of adults over age 60 report sleep disturbances. But, while age can be a factor on its own, sleep disturbances in elderly adults are often due to illnesses, certain conditions, or medications, according to the National Sleep Foundation.

Sleep problems are also extremely common for women approaching menopause. Research has found that up to 60 percent of women experience some type of menopause-related sleep disturbance, while another report revealed nearly 10 percent of women with menopausal symptoms reported chronic nighttime awakenings.

Talk to your doctor if you suspect menopause, a medication, or another condition is causing you to wake up. And look to lifestyle changes that help promote sleep such as getting regular exercise, eating a healthy diet, and maintaining a cool, dark, and quiet bedroom at night. Herbs can also help balance hormones and your health, helping to improve sleep quality, Dr. Rawls says.

Try general balancing herbs such as ashwagandha, as well as magnolia and phellodendron, two types of tree barks that have been used for centuries for their overall calming effect. Both were shown to alleviate mild anxiety in one study published in Nutrition Journal, and they reduced cortisol levels and perceived stress and fatigue, according to another study in the Journal of the International Society of Sports Nutrition.

9. Restless Leg Syndrome

About 10 percent of adults in the U.S. suffer from this neurological disorder, which causes an irresistible urge to move the legs and other uncomfortable sensations. These symptoms are especially prominent at night, and RLS commonly interferes with a good night’s rest. One study in the journal Sleep, for example, found a close link between periodic leg movements in the night and middle-of-the-night arousals.

If you suspect you have RLS, first see your healthcare provider to rule out any underlying conditions or causes. Otherwise, the best thing you can do is restore your health, Dr. Rawls says. Indeed, RLS is most common in those who are overweight, inactive or sedentary, and who smoke. “Improving your health habits and taking good care of yourself will help in the long term,” he says.

For example, yoga and other exercise have been shown to improve both symptoms of mild RLS and sleep in those with the condition. According to a study in Journal of the American Board of Family Medicine, exercising just three days a week — a mixture of cardio and lower-body resistance training — reduced RLS severity by 39 percent after just six weeks. Limiting sugar may also help, as can eating a healthy diet and taking iron and vitamin D supplements if you’re deficient.

How to cope if you wake up in the middle of the night

Regardless of what causes you to wake up, when you find yourself staring at the ceiling in the wee hours, all you really want is to fall back to sleep — the sooner the better. Here are a few tips that can help:

Consider naturally sedative herbs
For temporary nighttime waking and sleeplessness, several herbs act as natural sedatives. The strongest come from “effecting herbs” such as corydalis yanhusuo, California poppy, kava, jujube, skullcap, lobelia, and Western pasque flower, Dr. Rawls says. “These act both centrally and peripherally on GABA, a natural neurotransmitter that essentially turns your brain off and helps induce sleep.”

Bacopa, passion flower, and motherwort also affect GABA, but they are more gentle and balancing, Dr. Rawls says. They’re commonly used in traditional medicine for their calming powers. “Because they have a short half life, you can take them even in the middle of the night, and you won’t wake up groggy the next morning,” he says.

One warning: All herbs that impact GABA should only be taken intermittently — no more than a few nights in a row. Overuse may suppress the body’s natural production of GABA and could lead to more sleeplessness down the road.

Try magnesium and tart cherry
Magnesium is a muscle relaxant that acts like GABA in the brain, while tart cherry is a natural source of melatonin, a sleep-inviting hormone, Dr. Rawls says. In one study in the Journal of Research in Medical Sciences, researchers found that taking 500 mg of magnesium improved several markers of sleep in older adults. Small studies have likewise found tart cherry effective at improving sleep.

Avoid turning on lights or looking at a clock
Whether you wake up to use the bathroom or simply find yourself awake and can’t fall back asleep, keep the room and bathroom as dark as possible. “Once you turn on a light, it suppresses melatonin and tells your brain, ‘It’s morning, let’s go!’” Dr. Rawls says.

Looking at a clock can similarly activate your brain. Even if you don’t realize it, you may end up mentally calculating how many hours you have left before you must wake up, which can leave you feeling anxious and less able to fall back asleep.

Stay in bed and practice relaxation techniques
“One of the most common pieces of advice I hear is to leave your bed and go read — but I think that’s one of the most counterproductive things you can do,” says Dr. Rawls. “All it really does is wake up your brain more.”

Instead, he suggests first peeling off some covers to help cool down your body. “This is really important: Cooling down is very effective for helping the brain and body calm down and fall back to sleep,” says Dr. Rawls. Then, lie on your back and go through some simple breathing or meditation techniques to calm both body and mind so you’re able to drift off again.

Middle-of-the-night awakenings are a common frustration, but they don’t have to become part of your nightly regimen. Using the natural tips above should help you start to sleep through the night more regularly. But if they don’t and you’re still struggling to get enough quality Zzs, be sure to discuss it with your doctor — adequate sleep is truly essential to optimal health.

References
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2. National Institutes of Health, National Institute of Neurological Disorders and Stroke. “Brain Basics: Understanding Sleep.”
3. National Sleep Foundation. “How Alcohol Affects the Quality — and Quantity — of Sleep.”
4.Aparacida Crispim, Cibele, et. al. “Relationship between Food Intake and Sleep Pattern in Healthy Individuals.” Journal of Clinical Sleep Medicine. 2011 Dec 15; 7(6): 659–664.
5. Sun Han, Kuem, et. al. “Stress and Sleep Disorder.” Experimental Neurobiology. 2012 Dec; 21(4): 141–150.
6. Bolge, Susan C., et. al. “Burden of Chronic Sleep Maintenance Insomnia Characterized by Nighttime Awakenings Among Anxiety and Depression Sufferers: Results of a National Survey.” The Primary Care Companion to the Journal of Clinical Psychiatry. 2010; 12(2)
7. Chandrasekhar, K., et. al. “A Prospective, Randomized Double-Blind, Placebo-Controlled Study of Safety and Efficacy of a High-Concentration Full-Spectrum Extract of Ashwagandha Root in Reducing Stress and Anxiety in Adults.” Indian Journal of Psychological Medicine. 2012 Jul-Sep; 34(3): 255–262.
8. Kaushik, Mahesh K., et. al. “Triethylene glycol, an active component of Ashwagandha (Withania somnifera) leaves, is responsible for sleep induction.” PLOS ONE, 2017; 12 (2)
9. Jank, Robert, et. al. “Chronic Pain and Sleep Disorders in Primary Care.” Pain Research and Treatment. 2017; 2017: 9081802.
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11. Crippa, José A., et. al. “Translational Investigation of the Therapeutic Potential of Cannabidiol (CBD): Toward a New Age.” Frontiers in Immunology. 2018; 9: 2009.
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about the author
Dr. Bill Rawls
Dr. Bill Rawls has practiced conventional medicine as a gynecologist for
over 20 years and is also the co-founder and medical director of Vital Plan, a wellness and herbal supplement company.
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Dr. Bill Rawls

ABOUT BILL RAWLS, M.D.

Dr. Rawls graduated from Bowman Gray School of Medicine in 1985 and he holds a medical license in North Carolina. He also has extensive training in alternative therapies and is Medical Director of Vital Plan, an herbal supplement company in Raleigh, N.C.

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