Improve Sleep

A Strong scientific evidence

• Melatonin : The natural hormone known as melatonin helps to regulate sleep/wake cycles (circadian rhythm). Certain diseases such as cancer, prescription medications such as benzodiazepines, and age may decrease melatonin levels. Several human trials suggest that melatonin taken by mouth, started on the day of travel (close to the target bedtime at the destination) and continued for several days helps with symptoms of jet lag such as reducing the number of days required to establish a normal sleep pattern, diminishing the time it takes to fall asleep ("sleep latency"), improving alertness, and reducing daytime fatigue. Although these results are compelling, the majority of studies have had problems with their designs and reporting, and some trials have not found benefits. Overall, the scientific evidence does suggest benefits of melatonin in up to half of people who take it for jet-lag. More trials are needed to confirm these findings, to determine optimal dosing, and to evaluate use in combination with prescription sleep aids.
• Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks).

B Good scientific evidence

• Melatonin : Melatonin has been studied for delayed sleep phase syndrome (DSPS), insomnia in the elderly, sleep disturbances in children with neuro-psychiatric disorders, and sleep enhancement in healthy individuals. Although study results are promising, additional research with larger studies is needed before a conclusion can be made.
• Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks). Case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with overdose.
• Music therapy : Music is used to influence physical, emotional, cognitive and social well-being, and improve quality of life for healthy people, as well as those who are disabled or ill. It may involve either listening to or performing music, with or without the presence of a music therapist. In older adults music may result in significantly better sleep quality as well as longer sleep duration, greater sleep efficiency, shorter time needed to fall asleep, less sleep disturbance and less daytime dysfunction. There is also evidence of benefit in elementary age children who use music during naptime and bedtime. Music therapy is generally known to be safe.

C Unclear or conflicting scientific evidence

• 5-HTP (5-hydroxytryptophan) : 5-HTP is the precursor of the neurotransmitter serotonin. It is obtained commercially from the seeds of the plant Griffonia simplicifolia. Although many naturopathic regimens for sleep include 5-HTP, there is insufficient evidence in its use for sleep disorders or insomnia. Additional studies are needed before a conclusion can be drawn.
• 5-HTP may cause drug interactions with medications such as antidepressants and sleep medicines. 5-HTP is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
• Acupressure, Shiatsu : Shiatsu literally means finger (Shi) pressure (Atsu) in Japanese. Shiatsu technique involves finger pressure at acupoints and along body meridians (divisions). It may incorporate palm pressure, stretching, massaging and other manual techniques. Preliminary research suggests that acupressure may be beneficial for improving sleep quality and for providing early prevention and treatment for sleep apnea, a common cause of insomnia. Further research is necessary to confirm these findings.
• With proper training, acupressure appears to be safe if self-administered or administered by an experienced therapist. No serious long-term complications have been reported in the available literature. Hand nerve injury and herpes zoster ("shingles") cases have been reported after shiatsu massage. Forceful acupressure may cause bruising.
• Acupuncture : The practice of acupuncture originated in China 5,000 years ago. Traditional Chinese medicine commonly uses acupuncture to treat insomnia. A review of available studies found reports of benefit, but major weaknesses in the design of the research makes the evidence insufficient at this time.
• Needles must be sterile in order to avoid disease transmission. Avoid with valvular heart disease, infections, bleeding disorders, medical conditions of unknown origin, or neurological disorders. Avoid if taking drugs that increase the risk of bleeding (e.g. anticoagulants). Avoid on areas that have received radiation therapy and during pregnancy. Use cautiously with pulmonary disease (e.g. asthma or emphysema). Use cautiously in elderly or medically compromised patients, diabetics, or with history of seizures. Avoid electroacupuncture with arrhythmia (irregular heartbeat) or in patients with pacemakers because therapy may interfere with the device.
• Aromatherapy : Aromatherapy is a technique in which essential oils from plants are used with the intention of preventing or treating illness, reducing stress, or enhancing well-being. The oils are applied to the skin, sprayed in the air, or inhaled. Early research suggests that chamomile or lavender aromatherapy may be beneficial for improving sleep quality. Preliminary research also suggests that aromatherapy may be effective in the treatment of pediatric sleep apnea. More data are needed before definitive conclusions can be made.
• Avoid with history of allergic dermatitis. Use cautiously if driving/operating heavy machinery. Avoid consuming essential oils. Avoid direct contact of undiluted oils with mucous membranes. Use cautiously if pregnant.
• Ayurveda : Ayurveda, which originated in ancient India over 5,000 years ago, is probably the world's oldest system of natural medicine. There is evidence that a traditional Ayurvedic formula (Blissful Sleep®, Maharishi Ayurvedic Products International) containing valerian (Valeriana wallichi), rose petals (Rosa centifolia), muskroot (Nardostachys jatamansi), heart-leaved moonseed (Tinospora cordifolia), winter cherry (Withania somnifera), pepper (Piper nigrum), ginger (Zingibar officinalis), aloeweed (Convolvulus pluricalis), and licorice root (Glycyrrhiza glabra) may decrease sleep latency (time needed to get to sleep) in people with sleep-onset insomnia, with no side effects. Further research is needed to confirm these results.
• Ayurvedic herbs can interact with other herbs, foods, and drugs. A qualified healthcare professional should be consulted before taking. Ayurvedic herbs should be used cautiously because they are potent and some constituents can be potentially toxic if taken in large amounts or for a long time. Some herbs imported from India have been reported to contain high levels of toxic metals. Use guggul cautiously with peptic ulcer disease and avoid taking with sour food, alcohol, and heavy exercise. Avoid Ayurveda with traumatic injuries, acute pain, advanced disease stages, and medical conditions that require surgery.
• Chamomile : Chamomile (Matricaria recutita) has been used medicinally for thousands of years, and is widely used in Europe. Traditionally, chamomile preparations, such as tea and essential oil aromatherapy, have been used as a sleep aid and for sedation. Better research is needed.
• Chamomile is not recommended for individuals allergic to flowers in the daisy family, or during pregnancy or breastfeeding, unless otherwise advised by a doctor.
• Chiropractic : Chiropractic healthcare is a discipline that focuses on the relationship between musculoskeletal structure (primarily the spine) and body function (as coordinated by the nervous system), and how this relationship affects the preservation and restoration of health. The broad term "spinal manipulative therapy" incorporates all types of manual techniques, including chiropractic. Although physical manipulation is used traditionally for jet lag, there is not enough reliable scientific evidence at this time.
• Use extra caution during cervical adjustments. Use cautiously with acute arthritis, conditions that cause decreased bone mineralization, brittle bone disease, bone softening conditions, bleeding disorders, and migraines. Use cautiously with risk of tumors or cancers. Avoid with symptoms of vertebrobasilar vascular insufficiency, aneurysms, unstable spondylolisthesis, or arthritis. Avoid if taking drugs that increase the risk of bleeding. Avoid in areas of para-spinal tissue after surgery. Avoid if pregnant or breastfeeding due to a lack of scientific data.
• Creatine : Creatine is an amino acid that is produced in the muscles. Early studies of creatine in animals and humans have found mixed results in patients with a breathing disorder in infants called apnea of prematurity. Well-designed studies are needed to better understand this relationship.
• Avoid if allergic to creatine or if taking diuretics. Use cautiously with asthma, diabetes, gout, kidney, liver, or muscle problems, stroke, or with a history of these conditions. Avoid dehydration while taking creatine. Avoid if pregnant or breastfeeding.
• Focusing : Focusing (experiential therapy) is a method of psychotherapy that involves being aware of one's feelings surrounding a particular issue and understanding the meaning behind words or images conveyed by those feelings. Behavioral intervention may improve sleep, especially in those who chronically use medication to treat insomnia. More research is needed to determine whether focusing can effectively treat insomnia, and whether it can ease withdrawal symptoms when chronic users stop medication.
• Side effect reporting is rare, but patients should consult with a qualified healthcare practitioner before making decisions about medical conditions and practices. Individuals with severe emotional difficulties should not abandon proven medical and psychological therapies but rather choose focusing as a possible adjunct therapy.
• Guided imagery : Therapeutic guided imagery uses the power of the imagination as a healing tool. Guided imagery may be used to help patients relax and focus on images associated with personal issues they are confronting. Early research supports the value of combined pharmacotherapy and relaxation training in the treatment of insomnia. Further research is necessary.
• Guided imagery is usually intended to supplement medical care, not to replace it, and should not be relied on as the sole therapy for a medical problem.
• Hops : Hops may have sedative and sleep-enhancing (hypnotic) effects. However, little human research has evaluated the effects of hops on sleep quality and insomnia. Further study is needed in this area.
• Hops may cause drowsiness, so caution is used when operating an automobile or heavy machinery. Hops supplements are not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
• Hypnotherapy, hypnosis : Hypnotherapy or hypnosis uses the power of suggestion to help individuals overcome various health issues such as insomnia. Several early studies report that hypnosis may decrease the amount of time it takes to fall asleep, increase the duration of sleep, and improve sleep quality. However, this research is not well designed or reported, and cannot be considered definitive.
• Use cautiously with mental illnesses (e.g. psychosis, schizophrenia, manic depression, multiple personality disorder, or dissociative disorders) or seizure disorders.
• Kava : Kava may cause sedation or lethargy. However, early research suggests that kava may not be effective for insomnia. Additional study is needed in this area.
• Consult with a qualified healthcare professional before taking kava due to the risk of harmful side effects. Avoid if allergic to kava or kavapyrones. Avoid with liver disease, Parkinson's disease, a history of medication-induced extrapyramidal effects, and chronic lung disease. Avoid if taking medications for liver disease or CNS depressants such as alcohol or tranquilizers. Avoid while driving or operating heavy machinery (may cause drowsiness). Use cautiously with depression or if taking antidpressants. Avoid if pregnant or breastfeeding.
• Kundalini yoga : Kundalini yoga is one of many traditions of yoga that share common roots in ancient Indian philosophy. It is comprehensive in that it combines physical poses with breath control exercises, chanting (mantras), meditations, prayer, visualizations, and guided relaxation. Limited available study suggests improved sleep quality with the help of a regime of Kundalini yoga practices. However, there is insufficient evidence for or against this intervention for insomnia.
• Avoid exercises that involve stoppage of breath with heart or lung problems, insomnia, poor memory, or poor concentration. Avoid certain inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Use cautiously with mental disorders. Kundalini yoga is considered safe and beneficial for use during pregnancy and lactation when practiced under the guidance of expert instruction. Teachers of yoga are generally not medically qualified and should not be regarded as sources of medical advice for management of clinical conditions.
• Lavender : Lavender aromatherapy is often promoted as a sleep aid and hypnotic. Although early evidence suggests possible benefits, more research is needed before a firm conclusion can be drawn.
• Avoid if allergic or hypersensitive to lavender. Avoid with history of seizures, bleeding disorders, eating disorders (anorexia, bulimia), or anemia (low levels of iron). Avoid if pregnant or breastfeeding.
• Lemon balm : Lemon balm (Melissa officinalis) is a commonly used herb with a lemon like smell. High-quality clinical evidence supporting the use of lemon balm as a sedative/hypnotic is lacking, although it has been used with positive results with valerian for improving sleep quality. Rigorous clinical studies are required to better support the use of lemon balm as a sedative/hypnotic.
• Based on available research, lemon balm taken by mouth has been reported to be relatively well tolerated when taken for up to eight weeks. Evidence for topical administration of cream suggested minimal side effects for up to 10 days of application. Avoid if allergic or hypersensitive to lemon balm. Avoid with Grave's disease or thyroid hormone replacement therapy. Use cautiously in glaucoma because lemon balm may increase eye pressure. Use caution when operating heavy machinery. Lemon balm preparations may contain trace amounts of lead. Avoid if pregnant or breastfeeding.
• Lemongrass : Lemongrass is used in Brazilian folklore for nervous disturbances; however, early study of lemongrass has not confirmed its use for sedation. More research is warranted in this area.
• Avoid if allergic or hypersensitive to lemongrass, its constituents, or any members of the Poaceae family. Use cautiously if taking diabetic or cardiac medications or medications metabolized by cytochrome P450. Use cautiously with liver conditions. Avoid if pregnant or breastfeeding.
• Meditation : There is currently not enough clinical evidence indicating that meditation improves sleep disorders in patients with breast cancer, drug abuse problems, or in healthy subjects. Additional research is needed in this area.
• Use cautiously with underlying mental illnesses. People with psychiatric disorders should consult with their primary mental healthcare professionals before starting a program of meditation and should explore how meditation may or may not fit in with their current treatment plans. Avoid with risk of seizures. The practice of meditation should not delay the time to diagnose or treatment with more proven techniques or therapies. Meditation should not be used as the sole approach to illnesses.
• Melatonin : There is limited consistent evidence on the effectiveness of melatonin for circadian rhythm entraining in blind persons, insomnia of unknown origin in the non-elderly, REM sleep behavior disorder, sleep disturbances due to pineal region brain damage, or work shift sleep disorder. Better research is needed before a conclusion can be made.
• Caution is advised when taking melatonin supplements, as numerous adverse effects including drug interactions are possible. Melatonin is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor. Melatonin should not be used long-term (nightly for more than four weeks). Case reports raise concerns about risks of blood clotting abnormalities (particularly in patients taking warfarin), increased risk of seizure, and disorientation with overdose.
• Passionflower : Passionflower has a long history of use for sedation for reducing symptoms of restlessness, anxiety, and agitation. Early evidence from animal studies and weak human trials supports these uses. Better research is needed before a firm conclusion can be made.
• Avoid if allergic to passion flower or any of its constituents. Avoid consuming raw Passiflora fruit (Passiflora adenopoda), due to possible cyanide constituents. Avoid driving or operating heavy machinery while taking passion flower. Use cautiously with low blood pressure. Avoid if pregnant or breastfeeding.
• Relaxation therapy : Relaxation techniques include behavioral therapeutic approaches that differ widely in philosophy, methodology, and practice. The primary goal is usually non-directed relaxation. Most techniques share the components of repetitive focus (on a word, sound, prayer phrase, body sensation, or muscular activity), adoption of a passive attitude towards intruding thoughts, and return to the focus. Several human trials suggest that relaxation techniques may be beneficial in people with insomnia, although effects appear to be short-lived. Research suggests that relaxation techniques may produce improvements in some aspects of sleep such as sleep latency and time awake after sleep onset. Better research is necessary before a firm conclusion can be drawn.
• Avoid with psychiatric disorders such as schizophrenia/psychosis. Jacobson relaxation (flexing specific muscles, holding that position, and then relaxing the muscles) should be used cautiously with illnesses such as heart disease, high blood pressure, or musculoskeletal injury. Relaxation therapy is not recommended as the sole treatment approach for potentially serious medical conditions and should not delay the time to diagnosis or treatment with more proven techniques.
• Tai chi : Tai chi techniques aim to address the body and mind as an interconnected system. Tai chi may lead to improved sleep quality in older adults with sleep disorders. More studies are needed before definitive recommendations can be made.
• Avoid with severe osteoporosis or joint problems, acute back pain, sprains, or fractures. Avoid during active infections, right after a meal, or when very tired. Some believe that visualization of energy flow below the waist during menstruation may increase menstrual bleeding. Straining downwards or holding low postures should be avoided during pregnancy, and by people with inguinal hernias. Some tai chi practitioners believe that practicing for too long or using too much intention may direct the flow of chi (qi) inappropriately, possibly resulting in physical or emotional illness. Tai chi should not be used as a substitute for more proven therapies for potentially serious conditions. Advancing too quickly while studying tai chi may increase the risk of injury.
• Valerian : Valerian root (Valerian officinalis) has long been used as a sedative and anti-anxiety treatment. Although valerian has not been studied specifically as a sedative, evidence from studies conducted for other purposes suggests that valerian may not have significant sedative effects when used at recommended doses. Therefore, even though valerian could be helpful as a sleep aid, it does not appear to cause sedation. Several studies in adults suggest that valerian may improve quality of sleep and reduce the time to fall asleep (sleep latency), for up to four to six weeks. Ongoing nightly use may be more effective than single-dose use for insomnia, with effects increasing and then leveling out over the first four weeks of use. Better effects have been found in poor sleepers. However, most studies have not used scientific methods of measuring sleep improvements, such as sleep pattern data in a sleep laboratory.
• Caution is advised when taking valerian supplements, as numerous adverse effects including drowsiness and drug interactions are possible. Caution is also advised when operating heavy machinery or an automobile. Valerian is not recommended during pregnancy or breastfeeding, unless otherwise advised by a doctor.
• Yoga : Yoga is an ancient system of relaxation, exercise, and healing with origins in Indian philosophy. Preliminary research reports that yoga may benefit sleep efficiency, total sleep time, number of awakenings, and quality of sleep in patients with insomnia.
• Yoga is generally considered to be safe in healthy individuals when practiced appropriately. Avoid some inverted poses with disc disease of the spine, fragile or atherosclerotic neck arteries, extremely high or low blood pressure, glaucoma, detachment of the retina, ear problems, severe osteoporosis, cervical spondylitis, or if at risk for blood clots. Certain yoga breathing techniques should be avoided with heart or lung disease. Use cautiously with a history of psychotic disorders. Yoga techniques are believed to be safe during pregnancy and breastfeeding when practiced under the guidance of expert instruction. However, poses that put pressure on the uterus, such as abdominal twists, should be avoided in pregnancy.

D Fair negative scientific evidence

• Vitamin B12 : Taking vitamin B12 orally, in methylcobalamin form, with or without bright light therapy, does not seem to be effective for treating primary circadian rhythm sleep disorders. Additional research would help to confirm these results.
• Avoid if allergic or hypersensitive to cobalamin, cobalt, or any other vitamin B12 product ingredients. Avoid with coronary stents (mesh tube that holds clogged arteries open) and Leber's disease. Use cautiously if undergoing angioplasty and with anemia. Vitamin B12 is generally considered safe when taken in amounts that are not higher than the Recommended Dietary Allowance (RDA). There is not enough scientific data available about the safety of larger amounts of vitamin B12 during pregnancy and/or breastfeeding.