A guide to sleep aids: What are your options?

It’s 3 a.m. and you’ve been tossing and turning for hours. It’s the third time this week you’ve been ghosted by sleep and you’re getting desperate for some solid slumber. 

You’re not alone.

80% of people say they have trouble sleeping at least once a week, according to a 2018 Consumer Reports survey. With so many struggling with shut-eye, it should come as no big surprise, then, that sleep aids are a booming business. U.S. customers spend tens of billions of dollars each year on everything from herbal supplements to prescription sleep medications in the quest for better sleep.

Lack of sleep is a serious problem, but experts caution that there are pros and cons to every sleep aid marketed. Many don’t have a lot of scientific data proving their effectiveness. Still others work, but with side effects—like morning grogginess. And many times the sleep aid acts like a Band-Aid, masking, but never getting at the real root of your sleep problem. It could be a health issue such as obstructive sleep apnea (a sleep-related breathing disorder) or restless legs syndrome (a sleep-related movement disorder). Some sleep disorders need a medical evaluation and, usually, a medical intervention targeted to the problem.

“There’s no sleep aid that’s 100% without risk,” says Scott Kutscher, MD, a clinical associate professor of psychiatry and behavioral sciences at Stanford Sleep Sciences Center. “These drugs can cause oversedation, or, paradoxically, make people feel like they can’t sleep at all. Everyone is different. And what we lack is an understanding of each person’s individual neuro chemistry and the ability to say, ‘Okay, this is the right choice for you.’”

What’s the best drug-free option for insomnia?

Insomnia is loosely defined as difficulty falling or staying asleep with next-day drowsiness. It’s considered chronic insomnia if it occurs three nights or more a week for three or more months. Sleep medicine experts often suggest cognitive behavioral therapy to people who suffer from insomnia and aren’t getting restful sleep. “It appears to achieve similar results to sleeping pills without the potential side effects,” says Vishesh Kapur, MD, a professor of medicine in the division of pulmonary, critical care, and sleep medicine at the University of Washington School of Medicine. The therapy involves:

• Changing the way you think about sleep (e.g., instead of worrying about a lack of sleep, understand that everyone has trouble sleeping from time to time).
• Practicing relaxation therapies, such as deep breathing.
• Learning good sleep hygiene, which can make it more likely you’ll get a good night’s sleep. For example, don’t drink caffeine in the evening and keep your bedroom at a comfortable temperature.

The therapy is generally provided by a clinical psychologist. It’s best to look for one with a background in helping to change sleep habits.

What’s the most effective natural sleep aid?

That’s hard to answer. Large, well-designed scientific studies on natural sleep aids—which mostly consist of dietary and herbal supplements—are few and far between. Many of the studies out there have inconclusive findings. 

It’s also important to note that natural sleep aids are not approved by the U.S. Food and Drug Administration (FDA), which means they don’t undergo the rigorous testing for safety and effectiveness as other drugs. And since they’re not regulated, formulations and potencies can vary from one manufacturer to another and even one batch to another. 

The good news: Most natural remedies, which are easily found at drug, grocery, and health food stores, are considered safe to use for the short term, and side effects tend to be uncommon. When they do occur, they mostly come in the form of headaches and digestive issues, such as nausea, cramps, and diarrhea. 

“Many people may be able to use a sleep aid for a short period without side effects,” says Dr. Kapur. “But that doesn’t necessarily mean that long term there aren’t any consequences. Long-term risks have often not been evaluated.”

If you want to give a natural sleep aid a try, you should always talk to your doctor first, but here are a few popular options. 

Valerian root

Valerian root is an herb originating from the valerian plant grown in Europe, North America, and Asia. A review of studies looking at sleep and valerian, published in the journal Sleep Medicine Reviews, found “no significant differences between valerian and placebo, either in healthy individuals or in persons with general sleep disturbance or insomnia.” 

Still, some people find valerian effective—usually at helping them to fall asleep faster. No one’s really sure how it may work (when it does), but researchers think it may increase a chemical in the brain that has a calming effect. Valerian root is not recommended for pregnant or breastfeeding women or for those who take sedating medications like antidepressants and anti-anxiety drugs.

Melatonin 

Melatonin is a naturally occurring hormone produced by the brain. It increases at night, in response to darkness, and decreases in the day. It helps the body regulate its sleep-wake cycle (called the circadian rhythm), which is why melatonin supplements seem most effective in people with sleep problems related to jet lag or shift work. It also seems to work well in people who have difficulty getting to sleep (called sleep latency), say the experts at Penn Medicine in Philadelphia. But because it has a short life, meaning the body processes it quickly, it may not be ideal for people who wake a lot during the night, says Dr. Kutscher. 

Melatonin can interact with a fair number of drugs. Don’t take it if you’re taking sleeping pills, nonsteroidal anti inflammatories (NSAIDs), corticosteroids, blood thinners, antipsychotics, and/or drugs used to treat depression, anxiety, or high blood pressure. Because its active ingredient is a hormone, it can have effects on reproductive hormones. Melatonin is not recommended for use in children or in pregnant or breastfeeding women without a doctor’s consent.

Magnesium

Magnesium is a dietary mineral found in leafy greens, nuts, beans, whole grains, and other foods. It’s essential for a slew of bodily functions, including sleep. Research on the use of magnesium supplements as a sleep aid is limited, but in one study from 2012, elderly people taking 500 mg of magnesium oxide every night for eight weeks were able to fall asleep faster and stay asleep longer than subjects taking a placebo. 

It’s thought that a magnesium deficiency can cause problems in the body’s circadian rhythm and reduce levels of melatonin. Magnesium also helps increase the neurotransmitter GABA, which helps you feel more relaxed and calm. Magnesium supplementation can interfere with the absorption of medications such as antibiotics, and it can interact with others, such as blood pressure medicines. Proceed with caution.

What is the best over-the-counter sleep aid?

Most over-the-counter sleep medicines are simply re-packaged antihistamines, sometimes with a pain reliever such as acetaminophen or ibuprofen (think Tylenol PM and Advil PM). Antihistamines are drugs that are commonly used to treat allergy symptoms but that also have some sedating effects. They help promote drowsiness by blocking a chemical called histamine, which plays a role in regulating wakefulness. These OTC sleep aids are readily available at drugstores and supermarkets.

Most doctors say there’s nothing wrong with taking an antihistamine occasionally to help you fall asleep. But, they caution that you’re not likely to get high-quality sleep using one. You can suffer from side effects, including a next-day grogginess (aka, a sleep hangover), dry mouth, feelings of agitation, sleep walking, and confusion, especially if you’re elderly. Many people quickly build up a tolerance to the sedating effects of antihistamines, sometimes in a matter of weeks. 

Some of the over-the-counter antihistamines more commonly used for sleep are:

• Diphenhydramine, found in Benadryl , Zzzquil, and Aleve PM, among others
• Doxylamine succinate, found in Unisom, Nyquil, and others

Antihistamines shouldn’t be used by children under six or by anyone with breathing issues such as asthma, glaucoma, problems urinating (for example, from an enlarged prostate), heart disease, high blood pressure, or thyroid problems. If you do opt to take an occasional antihistamine for sleep, steer clear of products with an added pain reliever unless you need one. 

What will a doctor prescribe for insomnia?

Before prescribing a sleeping pill, your healthcare provider will want to evaluate you. Your physician may ask you to keep a sleep log to assess how much you sleep, how long it takes you to fall asleep, etc. You may have blood drawn to see if you have a medical problem that produces sleep problems, such as thyroid disease. You may even do an overnight sleep study, to help diagnose an issue like sleep apnea.

If your healthcare practitioner thinks a sleeping pill is right for you, he or she will prescribe one based on your symptoms. Some sleeping pills, such as Ambien and Sonata, work better for those who have trouble getting to sleep. Others, such as Lunesta and Restoril, are best for those who have issues staying asleep. 

In general, sleeping pills are for short term use, ideally for less than two weeks. “The clearest indication is for a problem that’s temporary,” says Dr. Kapur. “For example, when there’s anxiety or stress surrounding an upcoming work deadline.” Long-term use can cause dependency, which makes it harder than ever to sleep well without using the pills. Sleeping pills are not without side effects, which can include daytime drowsiness, dizziness, and, rarely, sleep walking/driving/eating. The following sleeping pills are commonly prescribed.

Benzodiazepines

These drugs have been used for decades to help manage sleep problems. They work on the neurotransmitter GABA, which can have a calming effect on the brain. Examples include: 

• Halcion
• Restoril
• Dalmane

Non-benzodiazepine hypnotics

Despite what the name implies, these drugs work similarly to benzodiazepines, helping to raise GABA levels in the brain. They more narrowly target GABA receptors than benzodiazepines, so they tend to have fewer side effects. Some brand names include:

• Sonata
• Lunesta

Orexin receptor antagonists

These are a new class of drugs recently approved by the FDA for sleep issues. They help block orexin, a brain chemical that makes you feel alert. Like non-benzodiazepine hypnotics, they are more selective in their targeting, so they come with fewer side effects. The only orexin receptor antagonist currently available is Belsomra (suvorexant).

What’s generally not prescribed for insomnia? Anti-anxiety medications like Xanax or Ativan. While they’re sedating, they tend to be more habit-forming and you can build up a tolerance to them. “They also tend to change a person’s sleep architecture,” says Dr. Kutscher. “They suppress REM and deep wave sleep, two stages that are critical for the health of the body and mind.”

What to consider before taking a sleeping aid

Sleep aids can be a good option for short-term use, but it’s best to get your doctor’s input and guidance before trying one. 

Consider the other supplements and medications you are taking—even if they are OTC. Pairing a sleep aid with a cold medication, such as Nyquil, or certain antidepressants can cause dangerous oversedation. 

People taking stimulants like Adderall, used to treat attention deficit disorder (ADD) and narcolepsy—an overwhelming daytime sleepiness—often complain of sleep problems. Your doctor may advise a sleep aid or change the timing of the stimulant to minimize nighttime effects. In other words, your doctor may need to tweak your medications and their dosages. 

Ask if your age or a condition raises your risk. A lot of sleep aids work on hormones and brain chemicals, so women who are pregnant or breastfeeding, children, and the elderly should be particularly cautious. Even if you fall into one of these categories, you may still be able to take a sleep aid. 

“There are a multitude of options available,” says Dr. Kutscher. “The key is understanding which medications have the least interaction with the things already being taken and to make sure the patient is aware of the potential side effects.” With the right treatment, you’ll be sleeping better soon.