In part 1 of this series, I looked at natural remedies for sleep. In part 2, below, I continue talking about sleep, looking at "sleep hygiene" (daily habits that can help or harm sleep), and then how to effectively use multiple, low-dose medications to address the sleep problems that are so common in CFS/FMS.
Good Sleep Hygiene
A number of daily and nightly habits will enhance your ability to fall asleep:
- Hot bath. Take a hot bath before bed.
- Cool room. Keep your bedroom cool.
- Caffeine-free. Don't consume caffeine after 4:00 pm.
- Alcohol early. Don't consume alcohol near bedtime.
- Snack to snooze. Have a light high-protein snack before bedtime. Hunger and hypoglycemia (low blood sugar) cause insomnia in all animals, and humans are no exception. Eat a 1-2 oz. high-protein snack at bedtime to see if this helps sleep (a hard-boiled egg, nuts, cheese, turkey, or other meat).
- Bedroom, not office. Don't use your bedroom for problem-solving or work.
- Ignore the clock. Put the bedroom clock out of arm's reach and facing away from you, so you can't see it. Looking at the clock frequently aggravates sleep problems — and it's frustrating!
- Solve snoring. If your partner snores, sleep in a separate bedroom (after tucking in or being tucked in by your partner). Or get a good pair of earplugs and use them. The wax plugs that mold to the shape of the ear are often best.
- Better bladder control. If you frequently wake up to urinate during the night, don't drink a lot of fluids near bedtime. Unfortunately most pain patients wake up during the night because of the pain or because their sleep center isn't working properly. Because they also have a full bladder, they think they're waking up because they have to urinate. But this is not the case. They are waking up because of their pain syndrome. The following is a simple way to remedy this problem: If and when you wake up during the night and notice your bladder is full, just talk to it (in your mind, so your spouse won't think you're nuts). Say, "Nighttime is for sleeping. We will go to the bathroom in the morning, when it is time to wake up." Then roll over and go back to sleep. If you still have to urinate five minutes later, go to the bathroom. Most of you will find that your bladder will happily go back to sleep — and when you wake up in the morning you won't even have to urinate as badly as you did when you woke up in the middle of the night. If the problem persists, the medication DDAVP 1/10 mg taken at bedtime can take care of nighttime urination.
Sleep Medications for Fibromyalgia
I much prefer natural remedies to prescription medications. But the sleep disorder in CFS/FMS patients may be too severe to be dealt with by natural remedies alone. However, even if you are someone who needs prescription sleep aids, adding natural remedies can be very helpful and usually decreases the amount of medication that you will need, resulting in fewer side effects. In addition, once you come off the sleep medications (usually after 9 to 18 months, although they can be used indefinitely if needed) you may find that all you require are the natural remedies. But whatever therapies you use, it's important that they not only increase the duration of sleep but also maintain or improve the deep stages (stages 3 and 4) of sleep. Unfortunately, most sleeping pills in common use (for example, Dalmane, Halcion and Valium) may actually worsen the quality of sleep by increasing the amount of light stage sleep (especially stage 2), and decreasing the stages of deep sleep. You want to be certain that the therapies and medications you use leave you feeling better the next day, not worse.
There are several approaches to sleep when addressing people with insomnia. Some doctors prefer to use a single medication or therapy, and push it up to its maximum level. If that works, great. If not, they stop it and switch to another medication. Other doctors prefer to use low doses of many different therapies together until the patient is getting good, solid sleep regularly. I strongly prefer the latter approach. Most of a medication's benefits occur at low doses and most of the side effects at high doses. In addition, if you combine low doses of a few different sleep aids, each of them will be cleared out of your body by morning — so you won't be hung over. Meanwhile, the effective blood levels that you have during the middle of the night from each therapy are cumulative, and will keep you asleep for eight to nine hours of solid sleep each night without waking or hangover.
To help you fall asleep, the key helpful medications are Ambien (my first choice), Lunesta, and Sonata. The other medications predominantly help you to stay asleep.
Here are some of the most helpful medications for sleep from our overall treatment protocol (there are many others):
- Ambien (Rx, zolpidem). 10 mg, ½-1 at bedtime. If you tend to wake during the night, leave ¼ of the tablet at bedside and take it as needed to help you sleep through the night (crush between your front teeth and put under your tongue).
- Neurontin (Rx; gabapentin). 100 mg, 1-6 caps at bedtime. This also helps pain and restless legs syndrome. It comes in 100-900 mg capsules or tablets
- Desyrel (Rx, trazodone). 50 mg, ½-2 at bedtime. Although sedating, it can be used (50-250 mg at a time) for anxiety. Do not take over 450 mg a day, or 150 mg a day if you are on other antidepressants.
- Flexeril (Rx, cyclobenzaprine). 5 mg ½-1 at bedtime. This is a muscle relaxant and can cause dry mouth.
- Doxylamine (Unisom for Sleep), Benadryl (diphenhydramine), or Dramamine (Dimenhydrinate). 25-50 mg at night (antihistamines). This may also help pain. All 3 of these are antihistamines, so do not take more than a total of 50 mg a night of any one or mix of these. They may increase dry mouth. Try each of them to see the effect, as one often works well when the others don't. These are available without a prescription.
- Doxepin (Rx, Sinequan). 5-10 mg, 1-3 capsules at bedtime or Doxepin liquid 10 mg/cc. If a lower dose is needed you can start with 1-3 drops at night. This is a powerful antihistamine. Some people get the greatest benefit with the least next-day sedation with a dose of less than 5 mg a night.
- Klonopin (Rx, clonazepam). ½ mg. Begin slowly and work your way up as sedation allows. Take ½ tablet at bedtime increasing up to 2 tablets at bedtime as needed. This can be very effective for sleep, pain and restless leg syndrome. Klonopin may be addictive. Taking one quarter to one half tablets in the morning (not more) can actually decrease brain fog in some CFS patients.
- Elavil (Rx, amitriptyline). 10 mg, ½-5 tablets at bedtime. This may cause weight gain or dry mouth. It is also good for nerve pain and vulvodynia.
- Zanaflex (Rx- Tizanidine). 4 mg, ½-1 tablet for sleep. Do NOT take while taking Cipro or Diflucan (fluconazole).
Jacob Teitelbaum, M.D. is one of the world's leading integrative medical authorities on fibromyalgia and chronic fatigue. He is the lead author of four research studies on their treatments, and has published numerous health & wellness books, including the bestseller on fibromyalgia From Fatigued to Fantastic! and The Fatigue and Fibromyalgia Solution. Dr. Teitelbaum is one of the most frequently quoted fibromyalgia experts in the world and appears often as a guest on news and talk shows nationwide including Good Morning America, The Dr. Oz Show, Oprah & Friends, CNN, and Fox News Health.