3 Steps for Managing Sleep Maintenance Insomnia

There may be no better feeling than waking up refreshed after an uninterrupted night of sleep. Unfortunately, this type of deep slumber is only a dream for millions of Americans with insomnia.

“Most people think of insomnia as difficulty falling asleep,” says behavioral sleep medicine psychologist Alicia Roth, PhD. “But maintaining sleep — in other words, staying asleep — is another common type of insomnia.”

This is known as sleep maintenance insomnia. An estimated 1 in 5 people with insomnia experience the sleep maintenance type. So, what is it and how can it be helped? Dr. Roth explains.

What is sleep maintenance insomnia?

Sleep maintenance insomnia occurs when you wake in the middle of the night but can’t fall back to sleep. Because this sleep disruption occurs midway through your sleep cycle, it’s also known as middle insomnia.

The timing of middle insomnia differs from:

• Early-onset (initial) insomnia, when you can’t fall asleep after turning in for the night.
• Late-onset (early-waking) insomnia, when you wake up an hour or so before you need to and can’t fall back asleep.

It’s also possible to have one or more sleep disruptions during the night (mixed insomnia).

Sleep maintenance insomnia symptoms

Three signs of sleep maintenance insomnia include:

1. Waking for no apparent reason in the middle of the night.
2. Taking 20 to 30 minutes to fall back to sleep.
3. Unusual daytime fatigue or sleepiness that affects your physical or mental health or ability to function.

What causes sleep maintenance insomnia?

“Sleep maintenance insomnia doesn’t always have an underlying medical or psychological cause,” says Dr. Roth.

But sleep maintenance insomnia can also be due to other conditions that wake you in the middle of the night, like:

• Anxiety or worry.
• Chronic pain.
• Depression.
• Frequent nighttime urination.
• Sleep apnea.

“Sleep maintenance insomnia may occur because your sleep drive is running out in the middle of the night. Every hour you are awake, your sleepiness or drive for sleep (called the homeostatic sleep drive) increases,” explains Dr. Roth. “There are many behaviors that can weaken your sleep drive, including having caffeine in the afternoon, napping too late in the day, or going to bed too early.”

Sleep maintenance insomnia risk factors

While there isn’t a primary cause for sleep maintenance insomnia, these factors can increase your risk:

• Age: The amount of time you spend in deep sleep decreases as you get older. This change can affect your circadian rhythm or sleep-wake cycle, causing you to wake in the night.
• Sex: Women and people assigned female at birth (AFAB) are more prone to all forms of insomnia.
• Hormones: People going through the stages of menopause often find it more difficult to stay asleep.

What to do if you have sleep maintenance insomnia

The first step to getting better sleep is seeking help.

“Too many people think disrupted sleep is something they must live with,” says Dr. Roth. “Your sleep needs change over the years, but that doesn’t mean you have to settle for poor quality sleep.”

These three steps can help determine what’s interrupting your slumber:

1. Talk to a healthcare provider

Depending on your symptoms, medical history and current life events, your provider may refer you for a sleep study. A sleep study identifies sleep disorders and other disruptive conditions such as:

• Obstructive sleep apnea.
• Snoring.
• Restless legs syndrome.

2. See a sleep specialist

Behavioral sleep medicine specialists have advanced training in identifying and addressing behavioral, psychological and physical factors that disrupt sleep. A provider may gather information about your:

• Diet, including how much caffeine you have each day and the time of day you consume it.
• Lifestyle habits, such as exercise, alcohol use and tobacco use.
• Sleep habits, including daytime naps.
• Views on how much sleep you need and sleep loss.

They’ll also work with you on identifying your ideal circadian rhythms and teach methods to regulate your homeostatic sleep drive.

3. Keep a sleep diary

A sleep diary is a helpful tool for tracking sleep patterns. You can also use a wearable device like a smartwatch to monitor sleep. Write that information into your sleep diary each morning to share with your provider, along with how you’re feeling when you’re going to bed and how you feel when you wake.

A sleep diary keeps track of:

• Diet, exercise, medications and substance use.
• Naps.
• Sleep efficiency (how much time you spend in bed sleeping versus lying awake).
• Sleep-wake cycle and disruptive sleep.
• Time it takes you to fall asleep or back to sleep.
• Total sleep time in a 24-hour period.

Sleep maintenance insomnia treatments

Taken together, the above steps can help your healthcare provider determine what’s disrupting your sleep and any potential solutions that can help you get back to getting a full night’s rest.

In general, studies show that sleep therapy — specifically, cognitive behavioral therapy for insomnia (CBT-i) — is the most effective way to improve sleep when you have sleep maintenance insomnia.

What is cognitive behavioral therapy for insomnia (CBT-i)?

Cognitive behavioral therapy (CBT) is a type of psychotherapy (talk therapy) that addresses how your thoughts, habits and behaviors interact to affect your mental health and outlook.

CBT for insomnia, or CBT-i, is a specialized form of CBT that identifies and addresses patterns that affect sleep.

“This therapy is the gold standard of treatment for all forms of insomnia,” says Dr. Roth. “It combines sleep education and therapy techniques to identify behaviors, emotions and beliefs that contribute to poor sleep, and recalibrate them to improve sleep.”

CBT-i focuses on these two key components:

1. Behaviors and habits, like:

• How you wind down before bed.
• What you do when you wake in the night.
• What time you go to bed and wake up.
• Whether you nap during the day.

2. Your relationship to or thoughts on sleep, like:

• Whether you go to bed expecting a poor night’s rest.
• How your emotions affect your slumber.

How else does CBT-i help?

CBT-i also incorporates sleep meditation tools, which help your body prepare for sleep and stay asleep. These tools include:

• Breathing exercises: Performing the 4-7-8 breathing technique or other forms of breathwork can help quiet your mind, decrease anxiety and lower blood pressure. Try doing breathwork while lying in bed before calling it a night.
• Relaxation exercises: Daily progressive muscle relaxation exercises can help you sleep more soundly. You tighten and release muscles while performing breathing exercises and body scan meditation.

What not to do if you have sleep maintenance insomnia

If you have sleep maintenance insomnia, focus on the following to avoid worsening your insomnia:

• Don’t drink caffeinated beverages like coffee or energy drinks too late in the day, as that can worsen insomnia.
• Try not to nap during the day to make up for missed sleep. Naps can interfere with your sleep-wake cycle. “Taking a nap after work might feel good in the moment,” notes Dr. Roth. “But it resets your sleep drive, making it less likely that you’ll sleep all night.”

Some additional steps you might take to overcome insomnia may help in small ways, but they won’t overall fix your sleep maintenance issues. For instance:

• Good sleep hygiene habits can help with early-onset insomnia. But practices like sleeping in a cool, dark room or banishing smartphones don’t usually cure sleep maintenance insomnia.
• Sleeping pills, including over-the-counter sleep aids and supplements like melatonin, are temporary fixes that work best for early-onset insomnia. “They may help you fall asleep faster, but they don’t get to the core of the sleep maintenance issue,” clarifies Dr. Roth.

Getting help for sleep maintenance insomnia

Most people with sleep maintenance insomnia enjoy improved slumber after four to eight in-person CBT-i sessions over a six- to eight-week period. But it can be challenging to find a professional with CBT-i training.

Ask your healthcare provider for a referral, rely on other resource directories like the Society of Behavioral Sleep Medicine, or consider trying Cleveland Clinic’s own online CBT-i program, Go! to Sleep℠. Roughly 3 in 4 people with insomnia who complete this six-week web-based program see meaningful, sustained improvements in the severity of insomnia symptoms, according to a Cleveland Clinic study.

“CBT-i requires more effort than taking a pill, but it’s more effective at improving sleep quality,” encourages Dr. Roth. “In a few weeks, this therapy can greatly enhance your relationship with sleep.”