It is 2:54 a.m., and you are wide awake. You try to go back to sleep but your mind is not cooperating. It is like a computer with too many tabs open. One by one, the thoughts start rolling in. The Amazon package you need to return. The appointment you keep forgetting to schedule. Tomorrow’s to-do list. And on and on it goes. Before you know it, an hour has passed. Now you are doing the math and calculating how much sleep you can get before your alarm goes off. The harder you try to sleep, the more awake you feel.
The comforting part is that waking up briefly during the night is a normal part of the sleep cycle. Actually, science explains this is normal. Sleep is lighter in the back half of the night and brief awakenings are part of a normal sleep structure. The real issue is what happens after waking up and how you respond.
Sleep Architecture: Why 3 a.m. Happens
Sleep is a naturally occurring reversible state of reduced responsiveness. There are two basic types of sleep: rapid eye movement (REM) sleep and non-rapid eye movement (non-REM) sleep. During a typical night, the body cycles through REM and non-REM sleep several times with each cycle lasting anywhere from 90-120 minutes.
Non-REM sleep has three stages:
- Stage 1: The transition from wakefulness to sleep that usually lasts only a few minutes.
- Stage 2: A period of light sleep before entering deep sleep. We spend more time in this stage of sleep than the other ones.
- Stage 3: Also known as deep sleep, this is the period of sleep where it is harder to awaken someone. This stage is restorative and makes us feel refreshed in the morning. The body prioritizes deep sleep during the first half of the night.
REM sleep is the part of sleep where most of your dreaming happens. We spend more time in light sleep and REM sleep during the second half of the night making it easier to wake up during that second half of the night.
Another factor that contributes to wakefulness is cortisol. Commonly referred to as the “stress hormone”, cortisol also plays a vital role in our natural sleep-wake cycle. Cortisol levels slowly rise during the early morning hours helping prepare the body for wakefulness.
Understanding the biology of our normal sleep cycle explains why waking up at 3 a.m. can be a normal part of a sleep cycle. But waking up is not necessarily the problem. What we do after is as important. In this article we will review 8 things to consider for managing nighttime awakenings.
Fix #1: Do Not Force Yourself to Sleep
For most people the first instinct after waking up in the middle of the night is trying harder to fall back asleep or check their phone to see how many hours are left before they have to wake up for the day. Unfortunately these reactions can make it harder to fall asleep. As frustration builds up, thoughts start to flood your mind. The more pressure you put on yourself to sleep, the harder it can become. According to the American Academy of Sleep Medicine, if you have been in bed awake for more than 20 minutes, consider getting out of bed and doing something relaxing like reading or listening to calm music in a dimly lit room. Return to bed when you feel sleepy again. This approach helps prevent your brain from associating your bed with being awake and gradually reinforces the connection between the bed and restful sleep.
Fix #2: Consistent Bedtime and Wake-Up Routines
Changing your bedtime and wake-up time can make it harder for your body to maintain a consistent sleep schedule. The circadian rhythm (also known as the internal clock) regulates when we feel sleepy and when we feel awake. Sleeping and waking up at approximately the same time daily helps maintain this rhythm. Being in natural light after waking and reducing light exposure and stimulating activities in the evening is essential as well. Taking naps especially in the late afternoon to compensate for previous nights of no sleep can be a hindrance to night sleep. Consistency is key. Maintaining a regular sleep schedule, even after a restless night, can help reinforce your body’s natural sleep-wake cycle over time.
Fix #3: Review Your Medication Timing
Some medications and supplements can interfere with our sleep cycles causing middle-of-the-night waking. Here are a few worth reviewing:
- Diuretics (water pills): taking diuretic medications in the evening can increase nighttime urination and lead to late night awakenings. This might make it difficult to fall back asleep. Discuss with your provider if you can take your water pills earlier in the afternoon to avoid frequent night trips to the bathroom.
- Antihistamines: medications such as diphenhydramine (Benadryl) which is also commonly contained in over-the-counter “PM” formulations can cause drowsiness and other side effects including confusion, dry mouth and constipation. The American Geriatrics Society recommends that adults 65 and older avoid Benadryl and other similar drugs due to increased risks of falls and confusion. Using these medications routinely for sleep is not recommended. Discuss alternatives with your provider.
- Steroid medications, stimulants and some decongestants can increase alertness and affect sleep.
- Caffeine and nicotine: these can contribute to night waking especially if used later in the day.
- Narcotics (oxycodone, hydrocodone, etc.) and benzodiazepines (diazepam, midazolam, etc.): these medications may cause daytime drowsiness and affect the quality of sleep at night.
The solution is not to stop or change the medications you take on your own. Ask your healthcare provider or pharmacist to review your medications and make any adjustments. This can make a meaningful difference in your sleep.
Fix #4: Melatonin Is a Bedtime Signal, Not a Sleeping Pill
Melatonin is a substance naturally produced by the body that helps regulate our circadian rhythm (internal clock). It signals to the body when it is time to sleep. Unlike most sleeping medications that cause sedation to make you sleep, melatonin primarily helps regulate the timing of sleep rather than directly inducing sleep. This means taking melatonin when you are already sleepy or about to fall asleep may miss the intended purpose of the medication. Timing is an important factor that can affect how well it works.
When it comes to how much to take, studies have shown that lower doses can be effective and taking higher doses does not always provide additional benefit. Melatonin is generally most useful when used for jet lag or for irregular sleep schedules where the body clock is out of order.
Fix #5: Night Sweats and Temperature Changes
Temperature plays an important role in sleep and changes in body temperature can trigger nighttime awakenings. Night sweats are a common experience for women during perimenopause or menopause. The changes in temperature may cause you to wake up or make it difficult to fall back asleep. Being aware of this and making simple adjustments like keeping the bedroom temperature cooler and wearing lighter sleepwear can help. If night sweats are happening frequently and affecting your sleep and daily life, consider bringing it up with your health care provider and discuss possible treatment options.
Fix #6: Limit Alcohol at Bedtime
Although we often think of a glass of wine as a way to wind down and relax before bed, alcohol can actually disrupt your sleep later in the night. Initially, alcohol has a sedating effect and can help you fall asleep faster and make sleep more consolidated during the first half of the night. However, it can also cause more fragmented sleep and frequent awakenings during the second half of the night. This can happen even at lower amounts of alcohol intake. If you are waking up around 3 a.m. regularly, it might be worthwhile to evaluate your alcohol intake especially around bedtime. This can help identify possible reasons for your nighttime awakenings. Consider reducing or changing the timing of your alcohol intake around bedtime if you have found an association.
If you drink alcohol heavily or regularly, do not suddenly stop drinking without medical guidance. Alcohol withdrawal can be dangerous and, in some cases, life threatening.
Fix #7: Avoid Late-Evening Bedtime Meals
What you eat and when you eat can also make an impact on the quality of your sleep. Eating too little or too much can both affect sleep quality. Changes in glucose levels in the body can affect different processes in the body that promote wakefulness. Going to bed full can cause indigestion and acid reflux, which can cause awakenings. Going to bed hungry can also make it harder to fall asleep.
In adults especially with diabetes, low blood sugar can also contribute to nighttime awakenings. The body’s hormonal response to low blood sugars includes releasing certain hormones like adrenaline to restore glucose levels. This response can cause sweating and sudden awakenings.
Avoiding large, heavy meals close to bedtime and maintaining regular, balanced eating habits can help improve sleep quality. If you have diabetes and suspect overnight low blood sugar, discuss appropriate glucose monitoring and medication adjustments with your healthcare team.
Fix #8: Cognitive Behavioral Therapy
If waking up in the middle of the night has become a persistent pattern, consider Cognitive Behavioral Therapy for Insomnia (CBT-I). It addresses the thoughts and behaviors that can keep insomnia going. CBT-I is the recommended first-line nonpharmacologic therapy for insomnia, often preferred over medications. Its benefits can last way beyond the treatment period. CBT-I uses several techniques, including stimulus control, sleep scheduling, and strategies to reduce sleep-related anxiety. These techniques can help break the cycle of frustration associated with struggling to fall back asleep after frequent nighttime awakenings.
What Not to Reach For
It is understandable to seek medications to tackle the problem of nighttime awakenings especially when they occur frequently. With an entire pharmacy aisle dedicated to sleep aids reaching for an over-the-counter medication can feel like an easy and convenient solution. But these medications can actually create more problems than they solve.
Many over-the-counter sleep aid medications contain sedating antihistamines such as diphenhydramine (Benadryl) or doxylamine (Unisom). They are also found in “PM” formulations of pain relievers including Tylenol PM and Advil PM.
These medications can make you feel drowsy without producing restorative sleep. In older adults, these medications may stay in the body longer and increase the risk of experiencing side effects.
Their use is generally not recommended for adults 65 years and older as the risks outweigh the benefits. Some of the side effects include dry mouth, constipation and confusion. These can be particularly concerning in the elderly leading to falls and other complications.
Before reaching for another medication, it is important to consider the underlying cause of your nighttime awakenings. Addressing the underlying problem rather than masking the symptoms with a medication can be the safer and long term solution.
When It Is Not Insomnia
Although there is a normal biological explanation for the 3 a.m. wake-up, not every middle-of-the-night awakening is healthy and harmless. If your sleep disruption is happening frequently and causing daytime fatigue and affecting daily quality of life, there is room to consider other factors that might be the cause.
A number of medical conditions can cause disruptions in sleep. Some include heart failure, chronic obstructive pulmonary disease (COPD), gastric reflux conditions, sleep apnea or pain. Mental health conditions like depression and anxiety can also lead to multiple night awakenings and poor quality of sleep.
For these types of situations the tips we considered in this article might not be the answer. Consider scheduling an appointment with your health care provider if your sleep disturbances are frequent or accompanied by other symptoms as these may require close monitoring or intervention. Treating the underlying problem might be the solution to restoring your sleep.
The Bottom Line
Waking up at 3 a.m. can be frustrating. Especially when you struggle to go back to sleep. But an occasional awakening during the second half of the night can be normal. Making small changes on how you respond to nighttime awakenings can make a meaningful difference in your sleep quality. If the disruptions are happening frequently, it might be beneficial to identify the underlying cause.
Selam Melka, PharmD, is a pharmacist with more than ten years of experience in clinical pharmacy and acute care.
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