Treatment for Excessive Sleepiness

Excessive daytime sleepiness (EDS) is the tendency to fall asleep during the daytime when one is expected to be awake. EDS can impact alertness, concentration, attention, and overall health. This health concern affects up to 18% of the U.S. population. EDS is not a sleep disorder in itself; instead, it is a symptom of other sleep-related disorders.

What are Common Causes of Excessive Daytime Sleepiness?

The following sleep disorders commonly cause excessive daytime sleepiness:

• Sleep apnea and other sleep-related breathing disorders
• Narcolepsy, with or without cataplexy
• Insomnia disorders, particularly in adolescents
• Circadian rhythm disorders such as delayed sleep phase
• Restless leg syndrome (RLS) and periodic limb movement disorder
• Insufficient sleep

Some psychiatric disorders—especially those that affect mood (anxiety, depression) or psychosis (schizophrenia) —can also impact sleep and can cause EDS. Heart failure, renal failure, liver failure, and obesity are medical conditions that can contribute to EDS. Neurological disorders including Parkinson’s, stroke, multiple sclerosis, and epilepsy also can affect EDS.

Other causes of EDS are inadequate sleep hygiene, excessive use of caffeine or other stimulants, chronic drug and alcohol use, and insufficient sleep. Sleep deprivation that leads to EDS is often a consequence of altered sleep patterns, like those that occur due to jet lag or shift work.

Sleep Hygiene and Excessive Daytime Sleepiness

A broad, nonpharmacologic step everyone with EDS can take is improving sleep hygiene. Proper sleep hygiene can lessen the effects of sleep-related disorders and promote overall health and wellbeing. To improve sleep hygiene:

• Ensure the sleep environment is dark, cool, and quiet
• Use the bed only for sex and sleep
• Exercise regularly during daytime hours
• Reduce consumption of alcohol, caffeine, and drugs
• Establish a consistent and relaxing bedtime routine, free from electronics whose bright screens emit light which includes the blue wavelengths
• If you cannot sleep after 20 minutes of lying in bed, get out of bed and find a quiet, relaxing activity until you are sleepy

What are Treatments for Disorders that Cause Excessive Daytime Sleepiness?

Other appropriate treatments for EDS depend on the underlying disorder. Work with your physician to accurately identify the cause of your EDS rather than making assumptions. As the disorders or causes are addressed—often using a combination of treatments—daytime sleepiness improves.

When it comes to treating EDS, physicians commonly identify one or more of the following underlying disorders and recommend the corresponding treatments:

• Sleep apnea. One of the most common treatments for sleep apnea of all severities is positive airway pressure (PAP). This is applied through the nose, mouth, or both through a machine, such as a continuous (CPAP) or bilevel (BPAP) machine.
• Narcolepsy is managed through behavioral therapy, timed short naps, and proper sleep hygiene. Wake-promoting medications, such as modafinil in combination with sodium oxybate, can also be used to help with staying awake during the day.
• Insomnia treatments vary. For both adolescents and adults, cognitive-behavioral therapy (CBT) is typically the first treatment approach. Pharmacological treatment is a secondary, short-term treatment to be pursued along with CBT. Prescribed drugs for insomnia include benzodiazepines, atypical antidepressants, antihistamines, and melatonin.
• Circadian rhythm disorders, such as sleep phase delay in adolescents, can be treated with a combination of light therapy in the morning and melatonin in the evening. Note that for adolescents, a prescription for melatonin may need to be written off-label. Other types of circadian rhythm disorders caused by jet lag and shift work can be treated by altering the sleep schedule ahead of travel and scheduling napping.
• Restless leg syndrome treatments, in addition to good sleep hygiene, include replacing iron determined to be deficient, other medications, pneumatic pressure therapy, and regular exercise.

What Medications are Available for People with Excessive Sleepiness?

Although there are many medications available for people with excessive sleepiness, they are often recommended along with other types of treatments, therapies, and behavior modifications. The following are commonly prescribed medications for patients with EDS:

• Modafinil (Provigil) is used to treat excessive sleepiness in patients with narcolepsy and residual sleepiness in certain cases of sleep apnea. Scientists believe the drug affects the sleep-wake centers in the brain. The most common side effect is a headache. More serious side effects can be the development of insomnia or nervousness, though these are uncommon.
• Armodafinil (Nuvigil) is similar to modafinil in that it is a wake-promoting agency used to treat sleepiness in patients who have narcolepsy or sleep apnea. Mild side effects are headache and dizziness. More serious side effects can include difficulty breathing or swallowing, depression, or thoughts of self-harm.
• Sodium oxybate (Xyrem) is used to treat narcolepsy. It increases the slow-wave sleep phase and by mechanisms not fully understood, improves daytime alertness. The drug limits sleep interruptions at nighttime. Side effects may include depression or confusion.
• Methylphenidate (Daytrana, Quillivant XR, Ritalin) is a stimulant used to treat narcolepsy  and encourage alertness. It is also prescribed to people who have ADHD. Some users can experience irritability, nervousness, or difficulty falling asleep at night.
• Benzodiazepine receptor agonists (Lunesta, Sonata, Ambien) are hypnotics that help with nighttime sleep. Improving quantity and quality of sleep at night can help reduce EDS. Dependency, loss of effectiveness, withdrawal symptoms, or overdose are among the risks with this class of drugs.
• Melatonin is a sleep hormone the human body releases naturally in the hours before bedtime. Some people with circadian rhythm disorders benefit from taking melatonin supplements before bedtime to help them fall asleep and wake up on time. Melatonin is available over the counter in the United States.

Consult your physician before starting or stopping any medication. Ensure they are fully aware of your health history, including allergies, and physical, and mental health diagnoses. Also, share with them any other medications, herbal supplements, or over-the-counter drugs you take, as these could interfere with your prescribed medication.

If you receive a prescription to treat excessive daytime sleepiness, carefully follow the directions provided by your physician and pharmacist. Avoid any potentially dangerous activities such as driving until you are sure of how the medication affects you.

Remember that these medications can have a variety of side effects. Take note of any side effects you experience and report them to your physician. In the case of an emergency, seek immediate medical attention.

Do “Wake Up Pills” and Supplements Have Any Effect?

There are some over the counter caffeine pills intended to help you “wake up,” and, at 200 mg, they often contain as much or more caffeine than a cup of coffee. Although some of these pills may provide an energy boost, they can also have negative side effects such as jitteriness, headaches, and increased heart rate. Excessive caffeine can also impact your circadian rhythm, making sleeping at night more difficult. Also, as a person becomes dependent on caffeine, it can be less effective at providing alertness.

Sometimes people opt for herbal supplements in hopes of obtaining better sleep. Common choices include chamomile, lavender, and kava. However, little research has been conducted on these supplements and there is little evidence to suggest their positive impact on sleep.

For instance, chamomile does not appear to help people with insomnia sleep better but may help improve the quality of sleep for people without insomnia. Kava can be used to treat anxiety, but there’s not enough research yet on its effect on sleep. Kava usage may add to a risk of liver injury.

Overall, it is better to focus on sleep quality and quantity whenever possible rather than relying on pills and supplements. A daily routine and good sleep hygiene will be most helpful and least likely to produce negative effects in the long-term.