What’s the Bottom Line?

What do we know about the usefulness of complementary approaches for sleep disorders?

• Relaxation techniques can be helpful for insomnia.

• Melatonin supplements may be helpful for sleep problems caused by shift work or jet lag. Melatonin may also be helpful for people with insomnia, but its effect is small.

• The evidence for other complementary approaches is either inconsistent or too limited to draw conclusions about whether they are helpful for sleep disorders.

What do we know about the safety of complementary approaches for sleep disorders?

• Relaxation techniques are generally considered safe.

• Melatonin appears to be relatively safe for short-term use, but its long-term safety has not been established.

• There are serious safety concerns about kava products (which have been linked to severe liver damage) and L-tryptophan supplements (which may be associated with a potentially serious disorder called eosinophilia-myalgia syndrome).

• If you use a complementary approach for a sleep problem, tell your health care providers. They can do a better job caring for you if they know what you’re using.

What Are Sleep Disorders and How Important Are They?

There are more than 80 different sleep disorders. This fact sheet focuses on insomnia—difficulty falling asleep or difficulty staying asleep. Insomnia is one of the most common sleep disorders.

Chronic, long-term sleep disorders affect millions of Americans each year. These disorders and the sleep deprivation they cause can interfere with work, driving, social activities, and overall quality of life, and can have serious health implications. Sleep disorders account for an estimated $16 billion in medical costs each year, plus indirect costs due to missed days of work, decreased productivity, and other factors.

Is It a Sleep Disorder or Not Enough Sleep?

Some people who feel tired during the day have a true sleep disorder, but for others, the real problem is not allowing enough time for sleep. Adults need at least 7 to 8 hours of sleep each night to be well rested, but the average adult sleeps for less than 7 hours a night.

Sleep is a basic human need, like eating, drinking, and breathing, and is vital to good health and well-being. Shortchanging yourself on sleep slows your thinking and reaction time, makes you irritable, and increases your risk of injury. It may even decrease your resistance to infections, increase your risk of obesity, and increase your risk of heart disease.

What the Science Says About Complementary Health Approaches and Insomnia

Complementary approaches can be classified by their primary therapeutic input (how the therapy is taken in or delivered), which may be:

• Nutritional (e.g., special diets, dietary supplements, herbs, probiotics, and microbial-based therapies).
• Psychological (e.g., meditation, hypnosis, music therapies, relaxation therapies).
• Physical (e.g., acupuncture, massage, spinal manipulation).
• Combinations such as psychological and physical (e.g., yoga, tai chi, dance therapies, some forms of art therapy) or psychological and nutritional (e.g., mindful eating).

Nutritional approaches include what the National Center for Complementary and Integrative Health (NCCIH) previously categorized as natural products, whereas psychological and/or physical approaches include what was referred to as mind and body practices.

Research has produced promising results for some complementary health approaches for insomnia, such as relaxation techniques. However, evidence of effectiveness is still limited for most products and practices, and safety concerns have been raised about a few.

Psychological and Physical Approaches

• There is evidence that relaxation techniques can be effective in treating chronic insomnia.
• Progressive relaxation may help people with insomnia and nighttime anxiety.
• Music-assisted relaxation may be moderately beneficial in improving sleep quality in people with sleep problems, but the number of studies has been small.
• Various forms of relaxation are sometimes combined with components of cognitive-behavioral therapy (such as sleep restriction and stimulus control), with good results.
• Using relaxation techniques before bedtime can be part of a strategy to improve sleep habits that also includes other steps, such as maintaining a consistent sleep schedule; avoiding caffeine, alcohol, heavy meals, and strenuous exercise too close to bedtime; and sleeping in a quiet, cool, dark room.
• Relaxation techniques are generally safe. However, rare side effects have been reported in people with serious physical or mental health conditions. If you have a serious underlying health problem, it would be a good idea to consult your health care provider before using relaxation techniques.
• In a preliminary study, mindfulness-based stress reduction, a type of meditation, was as effective as a prescription drug in a small group of people with insomnia.
• Several other studies have also reported that mindfulness-based stress reduction improved sleep, but the people who participated in these studies had other health problems, such as cancer.
• Preliminary studies in postmenopausal women and women with osteoarthritis suggest that yoga may be helpful for insomnia.
• Some practitioners who treat insomnia have reported that hypnotherapy enhanced the effectiveness of cognitive-behavioral therapy and relaxation techniques in their patients, but very little rigorous research has been conducted on the use of hypnotherapy for insomnia.
• A small 2012 study on massage therapy showed promising results for insomnia in postmenopausal women. However, conclusions cannot be reached on the basis of a single study.
• Most of the studies that have evaluated acupuncture for insomnia have been of poor scientific quality. The current evidence is not rigorous enough to show whether acupuncture is helpful for insomnia.

Nutritional Approaches

Melatonin and Related Dietary Supplements

• Melatonin may help with jet lag and sleep problems related to shift work.
• A 2013 evaluation of the results of 19 studies concluded that melatonin may help people with insomnia fall asleep faster, sleep longer, and sleep better, but the effect of melatonin is small compared to that of other treatments for insomnia.
• Studies of melatonin in children with sleep problems suggest that it may be helpful, both in generally healthy children and in those with conditions such as autism or attention-deficit hyperactivity disorder. However, both the number of studies and the number of children who participated in the studies are small, and all of the studies tested melatonin only for short periods of time.
• Melatonin supplements appear to be relatively safe for short-term use, although the use of melatonin was linked to bad moods in elderly people (most of whom had dementia) in one study.
• The long-term safety of melatonin supplements has not been established.
• Dietary supplements containing substances that can be changed into melatonin in the body—L-tryptophan and 5-hydroxytryptophan(5-HTP)—have been researched as sleep aids.
• Studies of L-tryptophan supplements as an insomnia treatment have had inconsistent results, and the effects of 5-HTP supplements on insomnia have not been established.
• The use of L-tryptophan supplements may be linked to eosinophilia-myalgia syndrome (EMS), a complex, potentially fatal disorder with multiple symptoms including severe muscle pain. It is uncertain whether the risk of EMS associated with L-tryptophan supplements is due to impurities in L-tryptophan preparations or to L-tryptophan itself.

Herbs

• Although chamomile has traditionally been used for insomnia, often in the form of a tea, there is no conclusive evidence from clinical trials showing whether it is helpful. Some people, especially those who are allergic to ragweed or related plants, may have allergic reactions to chamomile.
• Although kava is said to have sedative properties, very little research has been conducted on whether this herb is helpful for insomnia. More importantly, kava supplements have been linked to a risk of severe liver damage.
• Clinical trials of valerian (another herb said to have sedative properties) have had inconsistent results, and its value for insomnia has not been demonstrated. Although few people have reported negative side effects from valerian, it is uncertain whether this herb is safe for long-term use.
• Some “sleep formula” dietary supplements combine valerian with other herbs such as hops, lemon balm, passionflower, and kava or other ingredients such as melatonin and 5-HTP. There is little evidence on these preparations from studies in people.

Other Complementary Health Approaches

• Aromatherapy is the therapeutic use of essential oils from plants. It is uncertain whether aromatherapy is helpful for treating insomnia because little rigorous research has been done on this topic.
• A 2010 systematic review concluded that current evidence does not demonstrate significant effects of homeopathic medicines for insomnia.

If You're Considering Complementary Health Approaches for Sleep Problems

• Talk to your health care providers. Tell them about the complementary health approach you are considering and ask any questions you may have. Because trouble sleeping can be an indication of a more serious condition, and because some prescription and over-the-counter drugs can contribute to sleep problems, it is important to discuss your sleep-related symptoms with your health care providers before trying any complementary health product or practice.

• Be cautious about using any sleep product—prescription medications, over-the-counter medications, dietary supplements, or homeopathic remedies. Find out about potential side effects and any risks from long-term use or combining products.

• Keep in mind that “natural” does not always mean safe. For example, kava products can cause serious harm to the liver. Also, a manufacturer’s use of the term “standardized” (or “verified” or “certified”) does not necessarily guarantee product quality or consistency. Dietary supplements can cause health problems if not used correctly. The health care providers you see about your sleep problems can advise you.

• If you are pregnant, nursing a child, or considering giving a child a dietary supplement, it is especially important to consult your (or your child’s) health care provider.

• If you are considering a practitioner-provided complementary health practice, check with your insurer to see if the services will be covered, and ask a trusted source (such as your health care provider or a nearby hospital or medical school) to recommend a practitioner.

• Tell all your health care providers about any complementary health approaches you use. Give them a full picture of what you do to manage your health. This will help ensure coordinated and safe care.

Botanical medicine (herbalism or herbal medicine) has been practiced for millennia in many different cultures, with the earliest documented use of herbal medicine being 5000 years ago in China and India. As with any type of medicine, both risks and benefits exist.

In contrast to synthetic medications which usually contain one or perhaps two active ingredients, herbal treatments usually contain dozens or hundreds of bioactive compounds that may serve to modify the response or to reduce toxicity. This is one reason that clinical trials that isolate one putative active ingredient of an herbal treatment often find it to be ineffective. In contrast to drugs, herbals treatments are generally gentle and exert biological effects over longer periods of time than typical drug treatments do. Therefore, short randomized controlled trials (RCT’s) of herbal remedies, adapted from clinical trial methodology for drugs, are also often negative. Despite these issues, 80% of the total world population, and 95% of the developing world, uses herbal medicines. Whether they are guided by folk knowledge or have consulted an herbalist, they are often forced to evaluate a bewildering number of products, claims and labels without the benefit of any professional advice, especially in the US.

Nervines

“Nervine” is the term used in botanical or herbal medicine for herbs that are believed to act on the nervous system. Nervines are most often consumed in the form of a tea, although other formulations (e.g. tinctures) are also available. Nervines can be classified as nervine stimulants, nervine relaxants, and nervine tonics.

Nervine stimulants

Nervine stimulants are widely consumed throughout the US and the world. Although we seldom think of our morning coffee in this way, coffee is, in fact, a strong water-based extract made from the dried and roasted beans of Coffea Arabica. The main active ingredient in this nervine, caffeine, is well studied pharmacologically, and it is a potent adenosine antagonist. Adenosine is thought to mediate the homeostatic, or “Process S” sleep drive. This drive describes how the pressure to sleep increases linearly from the time of the last sleep period. Coffee is a good example of how a natural intervention in the form of a nervine stimulant can safely and effectively address a sleep-related symptom, sleep inertia, or somnolence due to inadequate sleep.

This is not to say that caffeine does not have toxicity, but when one considers that in the US alone, more than 400 million cups of coffee are consumed each day, and that worldwide, more than 2.25 billion cups of coffee are consumed daily with few reported fatalities for coffee overconsumption, the margin of safety is reassuring. Imagine how that would compare to stimulant medications like amphetamine or methylphenidate. In addition to caffeine, coffee contains many other bioactive compounds, including flavonoids that may offer benefits that cannot be obtained from simply taking caffeine tablets.

However, caffeine is almost certainly overused in our society, and it contributes greatly to insomnia and sleep complaints. Even in individuals without sleep complaints, the consumption of a single cup of coffee in the morning has measurable effects on sleep parameters. One recommendation that a health provider might feel comfortable making is that patients substitute green tea (Camellia sinensis) for at least some of the coffee they habitually consume.

In addition to having much less caffeine than coffee, green tea also contains high levels of various antioxidant flavonoids called catechins that may offer benefits including treating cardiovascular diseases, controlling body weight, increasing bone mass, protecting against neurodegenerative diseases and improving type 2 diabetes. Tea contains high levels of theanine as well. Theanine is a non-protein amino acid that appears to enhance dopamine release and result in inhibition of excitatory neurotransmission, thus acting as an anxiolytic.

Nervine relaxants

Nervine relaxants are also widely used worldwide (although nowhere near as frequently as coffee) to reduce tension, anxiety, and sleep disturbance. Many of these agents may have benefits that cross over to other organ systems. For example, chamomile (Matricaria recutita), one of the most common nervine relaxants, is helpful for insomnia, but also is useful for a nervous stomach. Unfortunately, similar benefits cannot be attributed to pharmaceutical sleeping medications. Specific nervine relaxants include the following:

German chamomile (Matricaria recutita). German Chamomile is one of the most widely used and versatile medicinal plants. It can be used as an infusion of the dried flowers or ethanolic extract. To prepare, pour 1 cup of boiling water over 2-3 heaping teaspoons (2-4 grams) of dried herb. Alternatively one can use 30-40 drops of a 1:5 45% alcoholic tincture, or take a solid extract as a 300-400 milligrams capsule. Taking a 200 milligram Chamomile extract capsule once daily for 28 days has been shown to significantly improve sleep quality in the elderly.[10] Another study demonstrated that taking 220-1100 milligrams of chamomile extract once daily for 8 weeks significantly decreased generalized anxiety. Chamomile may be taken thirty minutes prior to bedtime or three times daily for gastrointestinal (GI) symptoms.

Lemon balm (Melissa officinalis). Lemon balm has been used since the Middle Ages for anxiety and insomnia. It is often combined with other agents. In vitro studies have suggested that lemon balm is effective by acting as a GABA agonist. It is available as a dried herb and in extracts and tinctures. To prepare a tea, steep ¼ to 1 teaspoon (1.5-4.5 grams) of dried herb per cup of hot water. Capsules are taken at doses of 300-500 milligrams up to three times a day. The dose for a tincture is up to 60 drops daily. For insomnia and anxiety, one effective dose of a lemon balm extract is 300 milligrams twice daily for 15 days. Another study showed that 1200 milligrams of lemon balm extract once daily helped decrease the stress and tension related to premenstrual dysphoric disorder.

Valerian (Valerian officinalis). Valerian may be unique among insomnia remedies in that it may work better for insomnia with longer-term administration. Remind patients who choose to take it that this is the case; they may find it works better if they have been taking it for a few weeks. It is thought to work by increasing GABA levels in the brain. Valerian is available as a raw herb, but the odor is likened to that of an old goat or sweaty socks, so if it is consumed as a tea, it is often combined with other agents, in part to mask the stink. To make a tea, a person can pour 1 cup of boiling water over 1 teaspoon of dried herb and drink 5-10 minutes before bedtime. Alternatively, take 1 to 1.5 teaspoon of a 1:5 tincture or .5 to 1 teaspoon of a 1:1 fluid extract before bed. As a dry extract, 250-600 mg capsules before bed are also available. Many studies have suggested that 400-900 milligrams of valerian root extract up to 2 hours before bedtime has been helpful for insomnia.

Hops (Humulus lupulus). Hops are another widely used nervine relaxant. The flowering strobiles of the female hops plant contain high concentrations of active principles humulone and lupulone that remain present in the dried herb. The usual dose is 0.5 grams of the dried herb prepared as a tea or as a dry extract. Hops are thought to interact with melatonin receptors, and they are often combined with other agents such as valerian. Currently, available evidence suggests that a combination product including hops and valerian may improve sleep latency as compared to a placebo after 28 days of treatment. At this point in time evidence in support of hops use in improving sleep quality is mixed, and there are no available studies about the effects of hops when used as a monotherapy.

Kava kava (Piper methysticum). Kava kava has been traditionally used by indigenous peoples of the South Pacific. It is derived from the rhizomes of the kava shrub. Some of the health benefits of kava are known to be due to agents called kavapyrones, also known as kavalactones. Kava kava is a potent sedative and sleep-promoting agent. It has the potential for both hepatic and neurological toxicity with long-term use, and has actually been banned in some countries because of liver-related concerns. Kava is poorly soluble in water, so ethanol-water or acetone water extracts are typically used. Because of the potential for toxicity it is perhaps best not to routinely recommend its use. Clinicians who do suggest it often follow up with liver function lab tests. It is often included in multicomponent herbal sleep remedies, so careful label reading is essential. A recent systematic review suggested that kava may be beneficial for short term use (4-8 weeks) in the setting of generalized anxiety disorder. Recommended dose is 120-280  milligrams per day of Kavalactones.

Nervine tonics

Nervine tonics, unlike nervine stimulants or nervine relaxants, have no parallel in modern pharmacotherapeutics. Nervine tonics are thought to nourish and support the nervous system. One might think of them as restoring balance. The mechanisms of action are probably heterogeneous. Examples of this class of herbal remedies include the following:

Milky oats (Avena sativa). Milky Oats are prepared by expressing the juices of immature oats. The fluid is then made into a tincture. The customary dose is 20-40 drops 4 times a day. Milky oats are described as a nervous system restorative and nutritive tonic. It is traditionally recommended for those who give and give until they are themselves depleted.

Skullcap (Scutellaria lateriflora). Dried areal parts of this common weed can be made into a tea. Flavonoid constituents are weak GABA agonists. Other components bind serotonin receptors, but it is unclear whether they have an agonist or antagonist effect. Skullcap may be taken as an extract 1-2 grams daily. To prepare a tea, once can use 1-2 grams of dried herb steeped in 150 mililiters of boiling water for 5-10 minutes and then strain. According to Natural Medicines Comprehensive Database, adulteration with other scutellaria species can be a problem; there are many plants that are referred to as skullcap. Stick with reputable herbal suppliers and products. To date, there have been two clinical trials that have shown use of Skullcap to be correlated to a sense of relaxation and an overall mood improvement.The former study used a single dose of organic freeze-dried extract dosed between 100-350 miligrams, and the later study used 350 milligrams of freeze-dried extract 3 times daily for 2 weeks.

John’s Wort (Hypericum perforatum). St. John’s Wort has been an herbal treatment for more than 2000 years. Paracelsus (1493-1541) described its use to treat depression. Multiple studies have compared St. John’s Wort (SJW) to standard antidepressants and have found it to be as effective as tricyclic antidepressants (TCAs) and serotonin-specific reuptake inhibitors (SSRIs) in mild to moderate depression. (Apaydin, Eric A., et al. “A Systematic Review of St. John’s Wort for Major Depressive Disorder.” Systematic Reviews, vol. 5, no. 1, 2016, doi:10.1186/s13643-016-0325-2.) However, SJW is subject to multiple drug interactions, particularly through cytochrome 450 3A4 inhibitory effects. This supplement must be used with caution, and clinicians should familiarize themselves with specific interactions and use caution whenever a person could be taking it concomitantly with medications. Used with the guidance of an experienced herbalist or other practitioner, SJW may be a reasonable alternative to conventional antidepressants for mild to moderate depression. The usual dose is 300 milligrams 3 times a day for 6 weeks, standardized to 0.3% hypericin content.

Adaptogens

Adaptogens are a class of botanicals that have been in traditional use for thousands of years. They were extensively studied and developed in the Soviet Union as a means to help soldiers, athletes and even cosmonauts adapt to stress. Much of the data regarding these agents was classified and has been made available only since the dissolution of the Soviet Union. Adaptogens likely have multiple mechanisms of action, including bolstering the hypothalamic-pituitary (HPA) axis and providing weak cholinesterase inhibition. With acute stress, the HPA responds by releasing elevated levels of stress hormones, including cortisol. With chronic stress, the end organ—the adrenal glands— may become less able to respond in what is sometimes referred to as adrenal fatigue or exhaustion.

Sleep is often affected in both the acute and exhausted phase of the stress response. Adaptogens may be useful along with mind-body interventions to improve the resilience of the HPA in the face of acute and chronic stress, and as a result, they may improve sleep. Improved sleep is, of course, key in promoting hippocampal neurogenesis, an important step in HPA regulation.

Adaptogens can be used as single agents or combinations. Proprietary extracts are also used. A few examples are offered below; refer to the “Adaptogens” tool for additional details.

Ginseng Multiple botanicals are referred to as “ginseng.” Three of the most popular in the United States are American Ginseng (Panax quinquefolius), Korean ginseng (Panax ginseng) and Siberian Ginseng (Eleutherococcus senticosus), which is now required by law in the US not to be referred to as ginseng. All three herbs have been used as adaptogens. There is evidence that they may work by lowering elevated cortisol levels, and they also may lower post-prandial blood glucose in type 2 diabetes. Although Korean ginseng has been used to improve athletic performance, data supporting a benefit are lacking. Data are stronger for the use of Korean ginseng for erectile dysfunction. The main active ingredients of Korean ginseng, ginsenosides, have multiple potential actions. One recent study showed that Korean ginseng taken 24 hours after intense physical activity helped decrease muscle damage and HPA axis responses to this physical stress. Dosing is highly variable depending on the therapeutic aim.

Ashwagandha (Withania somnifera). Ashwagandha is a classical herb of Ayurveda (traditional Indian healing; refer to the “Ayurveda” section in Chapter 18 of the Passport to Whole Health) that is classified as a rasayana or rejuvenating herb. Like ginseng, it tends to lower elevated cortisol levels. Central nervous system effects may include decreasing stress-induced elevations in striatal dopamine, and ashwagandha seems to improve several markers of immune function as well. The typical dose is 1-6 grams of whole herb a day. A tea may be prepared by boiling the herb in water for about 15 minutes. The tea is cooled and then consumed 3-4 times throughout the day. Some evidence has pointed to triethylene glycol, a component of Ashwaganda leaves, as an inducer of non-REM sleep.

Rhodiola (Rhodiola rosea). Rhodiola is also known as golden root, andhas been used as a dietary herb and in traditional medicine in northern Europe and Asia for over 3000 years. It is felt to improve stamina and athletic performance. Rhodiola’s potential biological actions are complex. There is some data to support its use in generalized anxiety disorder. One randomized controlled trial showed self-reported improvement of anxiety, depression, mood, confusion, stress and anger after 14 days using a Rhodiola extract. Dosing depends on the indication and the specific proprietary extract. According to the Natural Medicines Comprehensive Database, the Rhodiola extract from Germany (Finzelberg, GmbH) has been dosed as 200 milligrams for a single dose or 100 milligrams twice daily. For depression, a specific Rhodiola extract (SHR-5) at 340 milligrams once daily or 340 milligrams twice daily has been studied. That same extract has been used for improving fatigue at doses of 50 milligrams twice daily, 170 milligrams daily, or a single dose of 370-555 milligrams. Side effects include agitation, insomnia, increased anxiety and palpitations. Because Rhodiola is mildly stimulating it should be used with caution in bipolar patients.

Common Names: chamomile, German chamomile

Latin Names: Matricaria recutita, Chamomilla recutita

Background

• There are two types of chamomile: German chamomile and Roman chamomile. This fact sheet focuses on German chamomile.
• Chamomile was described in ancient medical writings and was an important medicinal herb in ancient Egypt, Greece, and Rome.
• Today, chamomile is promoted for sleeplessness, anxiety, and gastrointestinal conditions such as upset stomach, gas, and diarrhea. It is also used topically for skin conditions and for mouth sores resulting from cancer treatment.

How Much Do We Know?

• Not much is known about the health effects of chamomile because there are few studies on chamomile in people for individual conditions. Also, some studies look at products made of chamomile plus other herbs, so it is difficult to know chamomile’s role from those studies.

What Have We Learned?

• Some preliminary studies suggest that a chamomile dietary supplement might be helpful for generalized anxiety disorder.
• Some research has found that products containing certain combinations of herbs that include chamomile may be of benefit for upset stomach, for diarrhea in children, and for infants with colic. But chamomile alone has not been shown to be helpful for these conditions.
• There’s very little information on chamomile’s effect on insomnia. A 2019 review of six small studies included only one study on insomnia. That one study found that chamomile had no benefit for insomnia. The same 2019 review looked at five studies on chamomile’s effect in non-insomnia populations. The review concluded that chamomile might help improve the individual component of sleep quality over a 4-week period in people without insomnia.

What Do We Know About Safety?

• Chamomile is likely safe when used in amounts commonly found in teas. It might be safe when used orally for medicinal purposes over the short term. The long-term safety of using chamomile on the skin for medicinal purposes is unknown.
• Side effects are uncommon and may include nausea, dizziness, and allergic reactions. Rare cases of anaphylaxis (a life-threatening allergic reaction) have occurred in people who consumed or came into contact with chamomile products.
• People are more likely to experience allergic reactions to chamomile if they’re allergic to related plants such as ragweed, chrysanthemums, marigolds, or daisies.
• Interactions between chamomile and cyclosporine (a drug used to prevent rejection of organ transplants) and warfarin (a blood thinner) have been reported, and there are theoretical reasons to suspect that chamomile might interact with other drugs as well. Talk to your health care provider before taking chamomile if you’re taking any type of medicine.
• Little is known about whether it’s safe to use chamomile during pregnancy or while breastfeeding.

Keep in Mind

• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Current clinical practice guidelines from the American Academy of Sleep Medicine (2021) and the American College of Physicians (2016) recommend psychological and behavioral interventions in the treatment of chronic insomnia disorder in adults.

• The American Academy of Sleep Medicine guidelines state: “We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia (CBT-I) for the treatment of chronic insomnia disorder in adults (strong recommendation). We suggest that clinicians use relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults (conditional recommendation).” The authors of the guidelines also noted that there were fewer than three studies meeting their inclusion criteria for the use of cognitive therapy, paradoxical intention, mindfulness, biofeedback, and intensive sleep retraining; as a result, no recommendations were made about these treatments.
• The American College of Physicians guidelines recommend CBT-I as the initial treatment for chronic insomnia disorder (strong recommendation, moderate-quality evidence).

What Does the Research Show?

• Clinical practice guidelines issued by the American Academy of Sleep Medicine in 2021 recommend psychological and behavioral interventions in the treatment of chronic insomnia disorder in adults. The guidelines state: “We recommend that clinicians use multicomponent cognitive behavioral therapy for insomnia (CBT-I) for the treatment of chronic insomnia disorder in adults (strong recommendation).”
• A 2018 analysis of pooled data from 4 randomized controlled trials of 546 peri- and postmenopausal women with insomnia and bothersome vasomotor symptoms found that CBT-I produced the greatest reduction in Insomnia Severity Index (ISI) from baseline compared to an education control.
• A 2014 randomized controlled trial examined the comparative efficacy of cognitive behavioral therapy, tai chi, and a sleep seminar education control in 123 older adults with chronic and primary insomnia. The study found that cognitive behavioral therapy performed better than tai chi and sleep seminar education in remission of clinical insomnia. The cognitive behavioral therapy group also showed greater improvement in sleep quality, sleep parameters, fatigue, and depressive symptoms than the tai chi and sleep seminar education groups.

Safety

• CBT-I is considered safe.

Common Names: kava, kava kava, ava pepper, ava root, kawa

Latin Names: Piper methysticum

Background

• Kava is native to the islands of the western Pacific and is a member of the pepper family.
• Pacific islanders have used kava for thousands of years as a medicine and for ritual purposes.
• Today, kava is promoted as a dietary supplement for anxiety, insomnia, and other conditions.

How Much Do We Know?

• There has been a fair amount of research in people on the use of kava for anxiety, but few studies have been done on other conditions.

What Have We Learned?

• Kava supplements may have a small effect on reducing anxiety, but they have been linked to a risk of severe liver injury.
• There isn’t enough evidence to show whether kava is helpful for any other conditions.

What Do We Know About Safety?

• The use of kava has been linked to liver injury that is sometimes serious or even fatal. The exact cause and frequency of the liver damage are unclear.
• Kava can cause digestive upset, headache, dizziness, and other side effects. The use of kava may affect the ability to drive or operate machinery. Long-term use of high doses of kava may cause kava dermopathy, a condition that involves dry, scaly, flaky skin with a yellow discoloration.
• Kava may have special risks if taken during pregnancy or while breastfeeding because of the presence of harmful pyrone constituents.

Keep in Mind

• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Chronic, long-term sleep disorders affect millions of Americans each year. These disorders and the sleep deprivation they cause can interfere with work, driving, social activities, and overall quality of life and can have serious health implications. Many people turn to complementary health approaches such as relaxation techniques or melatonin to help improve their sleep.

Recently, magnesium has gained popularity on the internet and across social media platforms as an ingredient in a “sleepy girl mocktail” for its purported ability to improve sleep. However, there is very little research on magnesium supplements for insomnia and other sleep disorders, so there isn’t enough rigorous scientific evidence to determine whether they are effective.

• For example, a 2021 review of 3 studies (151 participants) suggested that magnesium may help with sleep-onset latency (how quickly a person falls asleep) in older adults with insomnia. But the reviewers said the studies were of low quality and inadequate for making well-informed decisions on using magnesium.
• Another review of 9 studies (7,582 participants) showed conflicting findings for magnesium’s effect on sleep quality and sleep disorders. Some studies in this review found an association between higher magnesium intake and daytime falling asleep, sleepiness, snoring, and sleep duration in healthy adults; however, there was no association between magnesium and improvement in sleep disorder symptoms. Findings from other studies suggested some positive effect of magnesium on self-reported sleep, sleep efficiency, and sleep time, but the studies were small, and most were of low quality. Overall, the authors indicated that well-designed randomized clinical trials with larger sample sizes lasting more than 12 weeks are needed.

Magnesium in dietary supplements and medications should not be consumed in amounts above the upper limit, unless recommended by a health care provider. High intakes of magnesium from dietary supplements and medications can cause diarrhea, nausea, and abdominal cramping. Extremely high intakes of magnesium can lead to irregular heartbeat and cardiac arrest (when the heart stops beating).

There is some limited evidence that mindfulness meditation practices may help reduce insomnia and improve sleep quality.

What Does the Research Show?

• A 2019 systematic review and meta-analysis of 18 studies (1,654 total participants) found that mindfulness meditation practices improved sleep quality more than education-based treatments. However, the effects of mindfulness meditation approaches on sleep quality were no different than those of evidence-based treatments such as cognitive behavioral therapy and exercise.
• Results from a 2015 randomized controlled trial involving 60 adults aged 75 years and over with chronic insomnia suggest that the mindfulness-based stress reduction program could be a useful treatment for chronic insomnia for this age group.

Safety

• Meditation and mindfulness practices usually are considered to have few risks.

What is melatonin and how does it work?

Melatonin is a hormone that your brain produces in response to darkness. It helps with the timing of your circadian rhythms (24-hour internal clock) and with sleep. Being exposed to light at night can block melatonin production.

Research suggests that melatonin plays other important roles in the body beyond sleep. However, these effects are not fully understood.

Melatonin dietary supplements can be made from animals or microorganisms, but most often they’re made synthetically. The information below is about melatonin dietary supplements.

What are the health benefits of taking melatonin?

Melatonin supplements may help with certain conditions, such as jet lag, delayed sleep-wake phase disorder, some sleep disorders in children, and anxiety before and after surgery.

Jet lag

Jet lag affects people when they travel by air across multiple time zones. With jet lag, you may not feel well overall and you may have disturbed sleep, daytime tiredness, impaired functioning, and digestive problems.

Research suggests that melatonin supplements may help with jet lag. This is based on medium-sized reviews from 2010 and 2014.

• Four studies that included a total of 142 travelers showed that melatonin may be better than a placebo (an inactive substance) in reducing overall symptoms of jet lag after eastward flights. Another study of 234 travelers on eastward flights looked at only sleep quality and found low-quality evidence that melatonin may be better than placebo for improving sleep quality.
• Two studies that included a total of 90 travelers showed that melatonin may be better than a placebo in reducing symptoms of jet lag after westward flights.

Delayed sleep-wake phase disorder (DSWPD)

People with DSWPD have trouble falling asleep at the usual times and waking up in the morning. They typically have difficulty getting to sleep before 2 to 6 a.m. and would prefer to wake up between 10 a.m. and 1 p.m.

Melatonin supplements appear to help with sleep in people with DSWPD, but it’s uncertain whether the benefits outweigh the possible harms. This is based on a clinical practice guideline, a small review, and a more recent study.

• In 2015, the American Academy of Sleep Medicine recommended melatonin supplements given at specific times for DSWPD. The recommendation was a weak one, and it came with uncertainty about whether the benefits of melatonin outweigh its potential harms.
• A 2016 review that looked at a small number of people (52) from two studies showed that melatonin supplements reduced the time it took for people with DSWPD to fall asleep when compared to placebo. On average, it took about 22 minutes less for them to fall asleep.
• A 2018 randomized controlled trial that lasted 4 weeks and included 307 people with DSWPD found that taking melatonin 1 hour before the desired bedtime combined with going to bed at a set time led to several improvements. Those improvements included falling asleep an average of 34 minutes earlier, better sleep during the first third of the night, and better daytime functioning.

Some sleep disorders in children

Sleep problems in children can have undesirable effects on their behavior, daytime functioning, and quality of life. Children with certain conditions, such as atopic dermatitis, asthma, attention-deficit hyperactivity disorder (ADHD), or autism spectrum disorder (ASD), are more prone to sleep problems than other children.

There are no overall guidelines on the best approach to improving sleep in children. However, guidelines for specific conditions recommend behavioral treatments, such as good bedtime habits and parent education, as an initial treatment that may be supplemented with medicines.

• A 2019 review looked at 18 studies of melatonin supplements that included a total of 1,021 children. Most of the studies were small, and all were relatively brief (1 to 13 weeks). Overall, the studies showed that melatonin was better than placebo for improving both the time to fall asleep and total sleep. The effects of melatonin on behavior and daytime functioning, however, weren’t clear because the studies used different ways to measure these outcomes.

  The list below shows the review’s results on melatonin’s short-term effects for children with specific conditions.

  • Children with ASD fell asleep 37 minutes earlier and slept 48 minutes longer.
  • Children with ADHD fell asleep 20 minutes earlier and slept 33 minutes longer.
  • Children with atopic dermatitis fell asleep 6.8 minutes earlier and slept 35 minutes longer.
  • Children with chronic sleep-onset insomnia fell asleep 24 minutes earlier and slept 25 minutes longer.

Because there aren’t many studies on children and melatonin supplements, there is a lot we don’t know about the use of melatonin in children. For example, there are uncertainties about what dose to use and when to give it, the effects of melatonin use over long periods of time, and whether melatonin’s benefits outweigh its possible risks. Because melatonin is a hormone, it’s possible that melatonin supplements could affect hormonal development, including puberty, menstrual cycles, and overproduction of the hormone prolactin, but we don’t know for sure.

Because of these uncertainties, it’s best to work with a health care provider if you’re considering giving a child melatonin for sleep problems.

Anxiety before and after surgery

Anxiety before and after surgery happens in up to 80 percent of patients.

Melatonin supplements appear to be helpful in reducing anxiety before surgery, but it’s unclear if it helps to lower anxiety after surgery. This is a based on a 2015 review.

• The 2015 review looked at 12 studies that involved 774 people and assessed melatonin supplements for treating anxiety before surgery, anxiety after surgery, or both. The review found strong evidence that melatonin is better than placebo at reducing anxiety before surgery. Melatonin supplements may be as effective as standard treatment (the antianxiety medicine midazolam). However, the results on melatonin’s benefits for reducing anxiety after surgery were mixed.

Is melatonin helpful for preventing or treating COVID-19?

Current research looking at the effects of melatonin on COVID-19 is only in the early stages. There are a few randomized controlled trials (studies evaluating melatonin in people) in progress. At this point, it is too soon to reach conclusions on whether melatonin is helpful for COVID-19.

Does melatonin help with cancer symptoms?

Studies of the effect of melatonin supplements on cancer symptoms or treatment-related side effects have been small and have had mixed results.

Keep in mind that unproven products should not be used to replace or delay conventional medical treatment for cancer. Also, some products can interfere with standard cancer treatments or have special risks for people who’ve been diagnosed with cancer. Before using any complementary health approach, including melatonin, people who’ve been diagnosed with cancer should talk with their health care providers to make sure that all aspects of their care work together.

Can melatonin help with insomnia?

People with insomnia have trouble falling asleep, staying asleep, or both. When symptoms last a month or longer, it’s called chronic insomnia.

According to practice guidelines from the American Academy of Sleep Medicine (2017) and the American College of Physicians (2016), there’s not enough strong evidence on the effectiveness or safety of melatonin supplementation for chronic insomnia to recommend its use. The American College of Physicians guidelines strongly recommend the use of cognitive behavioral therapy for insomnia (CBT-I) as an initial treatment for insomnia.

Does melatonin work for shift workers?

Shift work that involves night shifts may cause people to feel sleepy at work and make it difficult to sleep during the daytime after a shift ends.

According to two 2014 research reviews, studies on whether melatonin supplements help shift workers were generally small or inconclusive.

• The first review looked at 7 studies that included a total of 263 participants. The results suggested that (1) people taking melatonin may sleep about 24 minutes longer during the daytime, but (2) other aspects of sleep, such as time needed to fall asleep, may not change. The evidence, however, was considered to be of low quality.
• The other review looked at 8 studies (5 of which were also in the first review), with a total of 300 participants, to see whether melatonin helped promote sleep in shift workers. Six of the studies were high quality, and they had inconclusive results. The review did not make any recommendations for melatonin use in shift workers.

Is it safe to take melatonin?

For melatonin supplements, particularly at doses higher than what the body normally produces, there’s not enough information yet about possible side effects to have a clear picture of overall safety. Short-term use of melatonin supplements appears to be safe for most people, but information on the long-term safety of supplementing with melatonin is lacking.

Also keep in mind:

• Interactions with medicines

  • As with all dietary supplements, people who are taking medicine should consult their health care providers before using melatonin. In particular, people with epilepsy and those taking blood thinner medications need to be under medical supervision when taking melatonin supplements.

• Possible allergic reaction risk

  • There may be a risk of allergic reactions to melatonin supplements.

• Safety concerns for pregnant and breastfeeding women

  • There’s been a lack of research on the safety of melatonin use in pregnant or breastfeeding women.

• Safety concerns for older people

  • The 2015 guidelines by the American Academy of Sleep Medicine recommend against melatonin use by people with dementia.
  • Melatonin may stay active in older people longer than in younger people and cause daytime drowsiness.

• Melatonin is regulated as a dietary supplement

  • In the United States, melatonin is considered a dietary supplement. This means that it’s regulated less strictly by the Food and Drug Administration (FDA) than a prescription or over-the-counter drug would be. In several other countries, melatonin is available only with a prescription and is considered a drug.

• Products may not contain what’s listed on the label

  • Some melatonin supplements may not contain what’s listed on the product label. A 2017 study tested 31 different melatonin supplements bought from grocery stores and pharmacies. For most of the supplements, the amount of melatonin in the product didn’t match what was listed on the product label. Also, 26 percent of the supplements contained serotonin, a hormone that can have harmful effects even at relatively low levels.

Is melatonin safe for children?

In addition to issues mentioned above, there are some things to consider regarding melatonin’s safety in children.

• Parents considering giving their children melatonin should first speak with a health care provider about melatonin use in children.
• Parents need to ensure safe storage and appropriate use of melatonin supplements.
• Use of over-the-counter melatonin might place children and teenagers at risk for accidental or intentional overdose.
  • A 2022 study indicated that U.S. sales of melatonin—which is widely available in tablet, capsule, liquid, and gummy formulations—increased by about 150 percent between 2016 and 2020. The study authors said that the increase in sales, availability, and widespread use of melatonin in the United States has likely resulted in increased access to melatonin among children in the home.
  • The 2022 study also showed that the number of reports to U.S. poison control centers about people 19 years and younger who took melatonin increased from 8,337 in 2012 to 52,563 in 2021. Over the 10-year period, the number of reports increased each year. Hospitalizations and serious outcomes from melatonin ingestion by people 19 years and younger also increased over the 10 years. Most hospitalizations involved teenagers who had intentionally taken melatonin overdoses, and the largest increase in hospitalizations occurred in children 5 years and younger.
  • Most of the calls to poison control centers—94.3 percent—were for children 5 years and younger who accidentally consumed melatonin products in their homes.
  • Data from the calls show that most of the people who had taken melatonin—82.8 percent—did not have any symptoms. Among those who did have symptoms, gastrointestinal, cardiovascular, or symptoms related to the central nervous system were the most common.
  • Of the 4,097 people who were hospitalized over the 10-year period, 287 needed intensive care.
  • Five individuals required mechanical ventilation, and two children younger than age 2 died, but the data from the poison control centers did not show whether the two deaths were caused by a melatonin overdose or another cause.

Melatonin supplements at normal doses appear to be safe for most children for short-term use, but there aren’t many studies on children and melatonin. Also, there’s little information on the long-term effects of melatonin use in children. Because melatonin is a hormone, it’s possible that melatonin supplements could affect hormonal development, including puberty, menstrual cycles, and overproduction of the hormone prolactin, but we don’t know for sure.

Possible melatonin supplement side effects reported in children have usually been mild and have included:

• Drowsiness
• Increased bedwetting or urination in the evening
• Headache
• Dizziness
• Agitation

What are the side effects of melatonin?

A 2015 review on the safety of melatonin supplements indicated that only mild side effects were reported in various short-term studies that involved adults, surgical patients, and critically ill patients. Some of the mild side effects that were reported in the studies included:

• Headache
• Dizziness
• Nausea
• Sleepiness

The possible long-term side effects of melatonin use are unclear.

Tips To Consider

• Remember that even though the FDA regulates dietary supplements, such as melatonin, the regulations for dietary supplements are different and less strict than those for prescription or over-the-counter drugs.
• Some dietary supplements may interact with medicines or pose risks if you have medical problems or are going to have surgery.
• If you’re pregnant or nursing a child, it’s especially important to see your health care provider before taking any medicine or supplement, including melatonin.
• If you use dietary supplements, such as melatonin, read and follow label instructions. “Natural” doesn’t always mean “safe.”
• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Current clinical practice guidelines from the American Academy of Sleep Medicine (2021) conditionally recommend relaxation therapy as a single-component therapy for the treatment of chronic insomnia disorder in adults. Guidelines from the American College of Physicians (2016) found insufficient evidence to determine the effect of relaxation therapy on global outcomes in the general population or iStylesn older adults with chronic insomnia disorder.

What Does the Research Show?

• Clinical guidelines from the American Academy of Sleep Medicine (2021) made a conditional recommendation to use relaxation therapy as a single-component therapy based on “a small body of low-quality evidence from five studies showing clinically meaningful improvements in one critical outcome, consideration that some patients prefer relaxation therapy, the fact that mental health providers are trained to deliver this form of treatment, and the potential for relaxation therapy to require only limited resources.”
• A 2018 systematic review looked at 27 studies of psychological interventions to try to improve sleep. The studies involved 2,776 college students who ranged from healthy sleepers to those with a diagnosed sleep disorder. About 22 percent of the studies investigated “relaxation, mindfulness, hypnotherapy” treatments. Similar to the guidelines from the American College of Physicians, this review recommended cognitive behavioral therapy to improve sleep in college students. The review also found that relaxation approaches helped somewhat with sleep quality and sleep problems but especially with mental health. The authors recommended that “relaxation, mindfulness, hypnotherapy” treatments be combined with cognitive behavioral therapy as a way to enhance mental health benefits.

Safety

• Relaxation therapies for insomnia are considered safe.

Results of several studies, using objective and subjective measures, have shown that tai chi may be helpful for people with sleep problems.

What Does the Research Show?

• A 2020 systematic review and meta-analysis of 20 randomized controlled studies from 5 countries involving a total of 1,703 patients found that compared with nontherapeutic and other active treatments, tai chi has a positive effect on improving sleep quality. An in-depth analysis showed that 24-form and 8-form Yang style tai chi had significant positive effects on sleep quality, as assessed by the Pittsburgh Sleep Quality Index (PSQI).
• A 2021 randomized controlled trial assigned 320 participants 60 years or older and with chronic insomnia to three groups: 12-week tai chi training, 12-week conventional exercise, and no intervention control. The study found that compared with the control group, the exercise and tai chi groups showed improved sleep efficiency, reductions of wake time after sleep onset, and reduced awakenings as measured by actigraphy. However, there were no significant differences between the exercise and tai chi groups.

Safety

• Tai chi appears to be safe. A 2019 meta-analysis of 24 studies (1,794 participants) found that the frequency of adverse events was similar for people doing tai chi, another active intervention, or no intervention.

Common Names: valerian, all-heal, garden heliotrope

Latin Names: Valeriana officinalis

Background

• Valerian is a plant native to Europe and Asia; it also grows in North America.
• Valerian has been used medicinally since the times of early Greece and Rome. Historically, valerian was used to treat insomnia, migraine, fatigue, and stomach cramps.
• Today, valerian is promoted for insomnia, anxiety, depression, premenstrual syndrome (PMS), menopause symptoms, and headaches.
• The roots and rhizomes (underground stems) of valerian are used for medicinal purposes.

How Much Do We Know?

• Knowledge about valerian is limited because a relatively small amount of research has looked at valerian’s effects on various conditions.

What Have We Learned?

• The evidence on whether valerian is helpful for sleep problems is inconsistent. In its 2017 clinical practice guidelines, the American Academy of Sleep Medicine recommended against using valerian for chronic insomnia in adults.
• Two small studies suggest that valerian might be helpful for menopausal symptoms, but there is not enough evidence to know for certain.
• There’s not enough evidence to allow any conclusions about whether valerian is helpful for anxiety, depression, premenstrual syndrome, menstrual cramps, stress, or other conditions.

What Do We Know About Safety?

• Research suggests that valerian is generally safe for short-term use by most adults. It has been used with apparent safety in studies lasting up to 28 days. The safety of long-term use of valerian is unknown.
• Little is known about whether it’s safe to use valerian during pregnancy or while breastfeeding.
• Side effects of valerian include headache, stomach upset, mental dullness, excitability, uneasiness, heart disturbances, and even insomnia in some people. A few people feel drowsy in the morning after taking valerian, especially at higher doses. Some people experience dry mouth or vivid dreams.
• Because it is possible (though not proven) that valerian might have a sleep-inducing effect, it should not be taken along with alcohol or sedatives.

Keep in Mind

• Take charge of your health—talk with your health care providers about any complementary health approaches you use. Together, you can make shared, well-informed decisions.

Yoga has been shown to be helpful for sleep in several studies of cancer patients, women with sleep problems, and older adults and in individual studies of other population groups, including people with arthritis and women with menopause symptoms.

What Does the Research Show?

• A 2020 systematic review and meta-analysis of 19 studies involving a total of 1,832 participants found positive effects of yoga in 16 randomized controlled trials, compared with the control group, in improving sleep quality among women using Pittsburgh Sleep Quality Index (PSQI); however, 3 studies revealed no effects of yoga compared to the control group in reducing insomnia among women using ISI. Seven studies revealed no evidence for effects of yoga compared with the control group in improving sleep quality for women with breast cancer using PSQI, while four studies revealed no evidence for the effects of yoga compared with the control group in improving the sleep quality for peri/postmenopausal women using PSQI.
• A 2020 secondary analysis of a randomized controlled trial involving 320 adults with chronic low-back pain and poor sleep quality prior to the intervention found modest but statistically significant improvements in sleep quality in the yoga (12 weekly yoga classes) and physical therapy groups.
• A 2019 systematic review of 11 studies that evaluated the use of yoga to manage stress and burnout in health care workers concluded that yoga is effective in improving physical problems and quality of sleep, as well as reducing stress levels and burnout. However, the authors of the review noted that it would be necessary to broaden the subject further and acquire more robust scientific evidence by designing and implementing research studies equipped with a solid methodological structure on bigger sample groups.
• A 2013 multicenter, randomized controlled trial evaluated the effect of yoga on sleep quality in 410 cancer survivors suffering from moderate or greater sleep disruption between 2 and 24 months after surgery, chemotherapy, and/or radiation therapy. The study found that compared with standard care, yoga participants demonstrated greater improvements in global sleep quality and subjective sleep quality, daytime dysfunction, wake after sleep onset, sleep efficiency, and medication use at postintervention.
• A 2022 randomized controlled trial investigated the effects of yoga (duration of 20 weeks) on menopausal symptoms and sleep quality across menopause statuses in 208 women. Based on participant responses to questionnaires, the study found that yoga decreased menopausal symptoms, with the strongest effects noted in postmenopausal women, followed by perimenopausal women. In addition, yoga significantly improved sleep quality in postmenopausal and perimenopausal women after controlling for social support, depression, anxiety, stress, and menopausal symptoms; however, yoga did not affect sleep quality in premenopausal women.

Safety

• Yoga is generally considered a safe form of physical activity for healthy people when performed properly, under the guidance of a qualified instructor. However, as with other forms of physical activity, injuries can occur.
• The most common injuries are sprains and strains, and the parts of the body most commonly injured are the knee or lower leg. Serious injuries are rare. The risk of injury associated with yoga is lower than that for higher impact physical activities.
• Hot yoga has special risks related to overheating and dehydration.
• Pregnant women, older adults, and people with health conditions should talk with their health care providers and the yoga instructor about their individual needs. They may need to avoid or modify some yoga poses and practices.

Chronic, long-term sleep disorders affect millions of Americans each year. These disorders and the sleep deprivation they cause can interfere with work, driving, social activities, and overall quality of life, and can have serious health implications. Sleep disorders account for an estimated $16 billion in medical costs each year, plus indirect costs due to missed days of work, decreased productivity, and other factors.

People who have trouble sleeping often try various dietary supplements, relaxation therapies, or other complementary health approaches in an effort to fall asleep faster, stay asleep longer, and improve the overall quality of their sleep. Here are 5 things to know about what the science says about sleep disorders and complementary health approaches.

1. Relaxation techniques may be helpful for insomnia. Evidence indicates that using relaxation techniques before bedtime can be helpful components of a successful strategy to improve sleep habits. Other components include maintaining a consistent sleep schedule; avoiding caffeine, alcohol, heavy meals, and strenuous exercise too close to bedtime; and sleeping in a quiet, cool, dark room.

2. Melatonin supplements may be helpful for some people with insomnia or sleep problems caused by shift work or jet lag. Research on the use of melatonin for children is more limited; available research suggests some benefit in children, but those studies were small and only addressed short-term use of melatonin. The long-term safety of melatonin has not been investigated.

3. Current evidence regarding other mind and body approaches such as mindfulness-based stress reduction (a type of meditation), yoga, massage therapy, and acupuncture is either too preliminary or inconsistent to draw conclusions about whether they are helpful for sleep disorders. These mind and body practices are generally considered safe for healthy people and when performed by an experienced practitioner.

4. Various herbs and dietary supplements sometimes used as sleep aids, including valerian, kava, chamomile, and L-tryptophan and 5-hydroxytryptophan (5-HTP) have not been shown to be effective for insomnia, and important safety concerns have been raised about a few. For example, the use of L-tryptophan supplements has been linked to eosinophilia-myalgia syndrome (EMS), a complex, potentially fatal disorder with multiple symptoms including severe muscle pain. Kava supplements have been linked to a risk of severe liver damage.

5. If you are considering a complementary health approach for sleep problems, talk to your health care providers. Trouble sleeping can be an indication of a more serious condition, and some prescription and over-the-counter drugs can contribute to sleep problems. So, it’s important to discuss your sleep-related symptoms with your health care providers before trying any complementary health product or practice.