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  • Difficulty initiating or maintaining sleep or nonrestorative sleep despite adequate opportunity and circumstances for sleep
  • Causes at least one of the following forms of daytime impairment related to nighttime sleep difficulty:
    • Fatigue or malaise
    • Attention, concentration, or memory impairment
    • Social or vocational dysfunction or poor school performance
    • Mood disturbance or irritability
    • Daytime sleepiness
    • Motivation, energy, or initiative reduction
    • Proneness for errors or accidents at work or while driving
    • Tension, headaches, or GI symptoms in response to sleep loss
    • Concerns or worries about sleep


  • Predominant age: increases with age
  • Predominant sex: female > male (5:1)

  • Insomnia (transient and chronic): 5–35% of the population; 10–15% associated with daytime impairment
  • Chronic insomnia: 10% middle-aged adults; 1/3 of people >65 years

Etiology and Pathophysiology

  • Transient/intermittent (<30 days)
    • Stress/excitement/bereavement
    • Shift work
    • Medical illness
    • High altitude
  • Chronic (>30 days)
    • Medical: gastroesophageal reflux disease, sleep apnea, chronic pain, congestive heart failure, Alzheimer disease, Parkinson disease, chronic fatigue syndrome, irritable bowel syndrome
    • Psychiatric: mood, anxiety, psychotic disorders
    • Primary sleep disorder: idiopathic, psychophysiologic (heightened arousal and learned sleep-preventing associations), paradoxical (sleep state misperception)
    • Circadian rhythm disorder: irregular pattern, jet lag, delayed/advanced sleep phase, shift work
    • Environmental: light (liquid crystal display [LCD] clocks), noise (snoring, household, traffic), movements (partner/young children/pets)
    • Behavioral: poor sleep hygiene, adjustment sleep disorder
    • Substance induced
    • Medications: antihypertensives, antidepressants, corticosteroids, levodopa-carbidopa, phenytoin, quinidine, theophylline, thyroid hormones

Pediatric Considerations
Transient insomnia occurs secondary to change of sleep position, nocturia, gastritis, back pain, and anxiety.

Risk Factors

  • Age
  • Female gender
  • Medical comorbidities
  • Unemployment
  • Psychiatric illness
  • Impaired social relationships
  • Lower socioeconomic status
  • Shift work
  • Separation from spouse or partner
  • Drug and substance abuse

General Prevention

  • Practice consistent sleep hygiene:
    • Fixed wake-up times and bedtimes regardless of amount of sleep obtained (weekdays and weekends)
    • Go to bed only when sleepy.
    • Avoid naps.
    • Sleep in a cool, dark, quiet environment.
    • No activities or stimuli in bedroom associated with anything but sleep or sex
    • 30-minute wind-down time before sleep
    • If unable to sleep within 20 minutes, move to another environment and engage in quiet activity until sleepy.
  • Limit caffeine intake to mornings.
  • No alcohol after 4 PM
  • Fixed eating times
  • Avoid medications that interfere with sleep.
  • Regular moderate exercise

Commonly Associated Conditions

  • Psychiatric disorders
  • Painful musculoskeletal conditions
  • Obstructive sleep apnea
  • Restless leg syndrome
  • Drug or alcohol addiction/dependence

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