Understanding Insomnia: Sleep Onset vs. Sleep Maintenance

Sleep is a fundamental component of overall health and well-being (1). Unfortunately, many of us struggle with sleep. The sleep struggle can often relate specifically to either falling asleep or staying asleep. Lack of sleep can significantly impact our health, daily functioning, mood, and overall quality of life (1). When someone frequently struggles with either falling asleep or staying asleep, we call that insomnia. We can further classify the type of insomnia as sleep onset insomnia or sleep maintenance insomnia (2).

This article explores the differences between these two types of insomnia, their causes, and strategies for achieving better sleep.

What is Sleep Onset Insomnia?

Sleep onset insomnia refers to difficulty falling asleep at the beginning of the night.

People with this condition often lie awake for extended periods, but once they manage to fall asleep, they generally sleep well for the rest of the night (3). This type of insomnia can lead to frustration and a negative association with bedtime, further exacerbating the problem.

Common Causes of Sleep Onset Insomnia

Several factors can contribute to sleep onset insomnia, including:

• Stress and Anxiety: Racing thoughts, worries, and anxiety can make it difficult to relax and fall asleep (4).
• Poor Sleep Environment: Noise, light, or an unsuitable room temperature can contribute to difficulty falling asleep (5).
• Irregular Sleep Schedule: Inconsistent sleep patterns, such as varying bedtimes, can confuse the body’s internal clock, making it harder to fall asleep (6).
• Caffeine and Stimulants: Consuming caffeine or other stimulants close to bedtime can interfere with the ability to fall asleep (7).
• Electronic Devices: Exposure to the blue light emitted by smartphones, tablets, TVs and computers can suppress melatonin production, delaying sleep onset (8).

What is Sleep Maintenance Insomnia?

Sleep maintenance insomnia refers to difficulty staying asleep throughout the night (2). Individuals with this condition may fall asleep relatively easily at the start of the night, but wake up frequently during the night or wake up too early in the morning and struggle to get back to sleep (2). This fragmented sleep can lead to daytime fatigue.

Common Causes of Sleep Maintenance Insomnia

Factors contributing to sleep maintenance insomnia include:

• Medical Conditions: Gastrointestinal issues (9), and respiratory conditions like sleep apnea (10) can cause frequent awakenings during the night.
• Alcohol: While alcohol may initially induce sleep, it can lead to fragmented sleep and frequent awakenings as the body metabolizes it (11).
• Hormonal Changes: Hormonal fluctuations, such as those experienced during menopause, can cause sleep disturbances (12). Imbalanced cortisol (a stress hormone) levels can also lead to waking up in the middle of the night (13).
• Blood Sugar Regulation: Fluctuations in blood sugar levels can cause awakenings and difficulty returning to sleep (14).
• Young Children: One of the hardest parts of parenting young children is the frequent night wakings.

How Does Insufficient Sleep Affect Health?

Both sleep onset insomnia and sleep maintenance insomnia can have significant consequences if left unmanaged. Insufficient or poor-quality sleep can lead to daytime fatigue, reduced concentration, and impaired cognitive function (15). Long term insomnia is associated with an increased risk of mood disorders, such as depression and anxiety (16). 

Additionally, lack of sleep can compromise the immune system over time. Studies show that people who don’t get enough sleep are more likely to get sick after being exposed to a virus (17). Lack of sleep can also affect how fast you recover if you do get sick (17). 

Persistent insomnia can also increase the risk of cardiovascular health events (18). Moreover, chronic lack of sleep can disrupt metabolic processes (19), such as insulin signaling.

For kids, insufficient sleep has the potential to cause issues such as decreased brain development, learning problems, and more frequent negative emotions (20). It can also contribute to weight management problems and growth issues (20).

How To Manage Insomnia

There is a lot that can be done to improve both sleep quality and quantity. Establishing a regular sleep schedule by going to bed and waking up at the same time every day, even on weekends, helps regulate the body’s internal clock, which regulates the production of melatonin, the hormone that helps us fall asleep (21). When you wake up in the morning, make an effort to get outside and expose your eyes to natural light, this practice sends signals to the brain that it is day time, further helping “set” the circadian clock (22).

Creating a consistent bedtime routine with calming activities such as reading or taking a warm bath can further signal to your body that it is time to wind down. It is important to limit exposure to electronic devices at least an hour before bed to prevent blue light from disrupting melatonin production (23). If screens must be used, consider using red-light glasses to block blue light.

It is also helpful to create an environment that is conducive to sleep. This means keeping the bedroom dark, quiet, and cool (24).

In my practice, I typically recommend avoiding caffeine after 11 am. Caffeine works by blocking adenosine, a neurotransmitter that promotes sleepiness. Caffeine has a half life (the time it takes for half of the caffeine to be metabolized by the body) of 4-6 hours (25). So if you drink your last cup of coffee by 11 am, by 5 pm about half of the caffeine will have left your body.

To learn more about caffeine intake during pregnancy or lactation, read Caffeine Consumption During Pregnancy and Lactation, and for caffeine-free energy support, read: Natural Energy Boosters For Exhausted Moms.

Strategies for Managing Sleep Onset Insomnia

In addition to the above strategies, for those struggling specifically with sleep onset insomnia, melatonin supplements can be particularly helpful. Melatonin is a hormone that helps signal to your body that it is time to sleep. Taking melatonin supplements about 30 minutes before bedtime can help promote sleep onset (26). 

To learn more about melatonin, read: Enhance Sleep Naturally With Dr. Green Mom’s Bedtime Mocktail and Top Seven Reasons Why I Prescribe Melatonin In My Integrative Medicine Practice  

Strategies for Managing Sleep Maintenance Insomnia

For managing sleep maintenance insomnia specifically, in addition to the above general sleep support tips, I recommend maintaining stable blood sugar levels by eating balanced meals and snacks, avoiding high-sugar foods before bed, and considering a small protein-rich snack before bedtime, if needed.

Blood sugar regulation is important for sleep maintenance insomnia because fluctuations in blood sugar levels can cause awakenings and difficulty returning to sleep (27). Low blood sugar during the night can trigger the release of stress hormones like cortisol (28), which can wake you up and make it difficult to fall back to sleep. 

If the cause of your frequent night wakings is a young child, the best way to support your own sleep will likely be to first support your child’s sleep. For some parents, safe co-sleeping helps everyone get more sleep. For older children, read the following articles for more ideas on how to best help them, and yourself, get the sleep you need: Sleep Essentials For Kids and 9 Reasons Your Kids Aren’t Sleeping (And How To Help).

Herbal Sleep Support for Sleep Onset Insomnia & Sleep Maintenance Insomnia

I am a big fan of herbal sleep support, both in terms of helping with sleep onset and maintaining sleep throughout the night:

Valerian Root: Valerian root is commonly used to improve sleep quality. Valerian root has the potential to increase levels of GABA (29), a calming neurotransmitter in the brain, which can help reduce the time it takes to fall asleep and improve overall sleep quality. 

Hops Strobiles: Hops Strobiles has sedative properties (30) that may help reduce the time it takes to fall asleep, supporting sleep onset insomnia.

Passionflower: Passionflower is another herb that can increase GABA levels in the brain (31), promoting relaxation and sleep. It is particularly helpful for those who have difficulty falling asleep due to anxiety (32). 

Chamomile: Chamomile tea is a popular bedtime remedy. This herb can also be consumed in supplement form or utilized in essential oil form. Research shows that chamomile is associated with “significant improvement in sleep quality” (33).

California Poppy: Fresh California poppy is used for its sedative properties and can help improve sleep quality and reduce nighttime awakenings (34). Research shows that California Poppy may be especially supportive of sleep when used in combination with Valerian Root (34). 

Lemon Balm: Lemon balm has a mild sedative effect and can help reduce anxiety and promote calmness (35).

Always consult with a healthcare provider before starting any new herbal regimen, especially if you are taking other medications, pregnant, breastfeeding, or have underlying health conditions.

Summary

Understanding the differences between sleep onset insomnia and sleep maintenance insomnia can be helpful for effectively managing these conditions. Both types of insomnia can significantly impact daily life due to the effects of lack of sleep, including daytime fatigue, changes in mood, and compromised immune function. General strategies for improving sleep quality and quantity include establishing a regular sleep schedule, creating (and sticking to) a calming bedtime routine, optimizing the sleep environment, and limiting caffeine and screen time before bed. 

For those struggling specifically with sleep onset insomnia, melatonin supplements can be helpful. Managing sleep maintenance insomnia involves addressing underlying conditions that may be causing the awakenings, maintaining stable blood sugar levels, and considering herbal support. Herbs like valerian root, hops strobiles, passionflower, chamomile, California poppy, and lemon balm can all support better sleep quality and duration. 

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