Why do I have such a hard time falling asleep?

Usually because your alertness system is still running at bedtime: stress or worry, caffeine or alcohol too late, screens and bright light in the evening, an irregular schedule, or a bedtime earlier than your body clock. Once it has gone on for a while, the worry about not sleeping becomes its own cause. Restless legs and pain are the medical causes we check first.

How is insomnia diagnosed?

From the history and a one- to two-week sleep diary, plus a medication review and an examination. There is no scan or blood test for insomnia. A sleep study is ordered when something points to sleep apnea or leg movements during sleep, not to confirm insomnia.

Can chronic insomnia be cured?

For most people it can be brought under control, and many stay well once CBT-I has reset the habits that were sustaining it. Relapses in stressful periods are common and usually respond to the same techniques. When another condition is driving the insomnia, treating that condition is what makes the difference.

Can insomnia cause permanent damage?

Chronic insomnia is associated with higher rates of depression, high blood pressure, and cognitive complaints, and it makes most other neurological conditions harder to manage. Mood, concentration, and daytime function generally recover once sleep is treated, which is the reason to address it rather than live with it.

Do I need a sleep study for insomnia?

Not for insomnia itself, which is diagnosed from the history. We order one when something points to sleep apnea or leg movements during sleep, such as snoring, witnessed breathing pauses, or waking with a headache.

What is the difference between insomnia and sleep apnea?

Insomnia is difficulty sleeping, usually driven by arousal, habits, or mood. Sleep apnea is a breathing disorder: repeated pauses that wake you briefly without your remembering. Both cause daytime fatigue, they often coexist, and only a sleep study can diagnose the apnea.

What if I sleep too much rather than too little?

Sleeping ten or twelve hours and still feeling unrefreshed is a different problem, and it more often needs a sleep study than insomnia does. The common causes are sleep apnea, depression, sedating medications, and, less often, narcolepsy or another disorder of excessive sleepiness.

When should I see a neurologist for sleep problems?

If insomnia has lasted three months or more, is getting worse, is affecting your daytime function or mood, or if you suspect sleep apnea, restless legs, or a circadian rhythm disorder. Persistent sleep problems deserve a proper workup, not just a prescription.

Insomnia: Causes, Symptoms and Treatment from a Neurologist

Insomnia: Understanding Causes, Symptoms, and Treatments

Insomnia is trouble falling asleep, staying asleep, or waking too early despite enough opportunity to sleep, and it counts as chronic once it happens three or more nights a week for three months. The treatment recommended first is cognitive behavioral therapy for insomnia, not sleeping pills. A neurologist's job is to find the conditions that drive or mimic it, such as sleep apnea, restless legs, pain, or medication effects.

Medically reviewed by Dr. Achillefs Ntranos, MDPublished September 14, 2024Updated September 3, 202610 min read

Insomnia is the most common sleep complaint we hear about, and one of the most frustrating, because the harder you try to sleep the worse it usually gets. The good news is that the treatment with the best long-term evidence is not a pill.

What insomnia is

Insomnia is difficulty falling asleep, staying asleep, or both, despite adequate time and opportunity. That last part matters. Someone who sleeps six hours because they allow six hours does not have insomnia, they have a schedule problem.

	How long	What is driving it
Acute	Days to a few weeks	An obvious trigger: illness, travel, a deadline, a loss
Chronic	Three or more nights a week for three months	The trigger has usually passed. What sustains it is worry about sleep and the habits built around it

The nights look like trouble getting off to sleep, waking and not getting back, waking too early, or sleep that never feels restorative. The days are where the damage shows: fatigue, irritability, trouble concentrating, and headaches.

A bed beneath three window scenes showing evening, nighttime, and dawn. — Insomnia can affect the beginning, middle, or end of the night.

A softly rumpled bed and pillow in a quiet moonlit room.

Causes of insomnia

In most people who come to us, more than one of these is in play, which is why treating a single cause is often not enough.

Category	Examples
Mood and stress	Anxiety, depression, PTSD, and the ordinary stress that started an acute episode
Other sleep disorders	Sleep apnea and restless legs syndrome, both of which imitate insomnia
Medical	Chronic pain, hormonal changes around menopause, thyroid disease
Neurological	Dementia, Parkinson's disease, multiple sclerosis
Medications and substances	Some antidepressants, steroids, decongestants, beta blockers, caffeine, nicotine, and alcohol
Schedule and environment	Shift work, travel across time zones, irregular bedtimes, late-evening screens, noise, light, heat

Insomnia is more common in older adults and in women, and the risk rises with shift work, chronic illness, and family history.

Why it keeps going after the trigger has passed

Sleep specialists think about chronic insomnia in three layers. Some people are predisposed: light sleepers, worriers, people whose alertness runs high. Something precipitates it: a stressful month, an illness, a new baby. Then a set of understandable reactions perpetuates it after the trigger is gone: going to bed early to catch up, lying awake for hours, napping, watching the clock, and coming to dread the bedroom, until the bed itself becomes a cue for being awake. This is why the question that matters in chronic insomnia is often not what started it but what is keeping it going, and why the most effective treatment targets those habits directly.

How insomnia is diagnosed

There is no scan or blood test for insomnia. What a careful evaluation does is separate primary insomnia from the conditions that cause or imitate it, because those are treated differently.

A detailed sleep history
When you go to bed, how long it takes to fall asleep, how often you wake, what you do when you cannot sleep, and what your days look like afterwards.
A full medication and substance review
Every prescription, supplement, and over-the-counter product, plus caffeine, nicotine, and alcohol. This is where the cause turns up more often than people expect.
A sleep diary for one to two weeks
More informative than any single visit, because it shows the pattern rather than your memory of it.
An examination, and targeted tests
We check for signs of a contributing condition. Blood tests are sometimes useful, such as thyroid function or a ferritin level when restless legs is suspected. A sleep study is ordered only when the history points to sleep apnea or leg movements during sleep, not for insomnia itself.

Treatment options

The order matters. Treating a cause such as sleep apnea, restless legs, or pain comes first, because a sleep aid layered on top of an untreated cause rarely works for long.

Cognitive behavioral therapy for insomnia (CBT-I) is the treatment guidelines recommend first, and the one with the best long-term results. It is a structured program over several weeks that retrains the association between bed and sleep. Its two main components are sleep restriction, in which time in bed is matched to the hours actually slept and then gradually widened as sleep becomes more solid, and stimulus control, in which the bed is reserved for sleep and time awake is spent elsewhere. Both are set up and adjusted by the therapist delivering the program.

The honest caveat: the first weeks of sleep restriction are tiring, and most people who quit do so in that window. We do not deliver CBT-I ourselves. We refer to a therapist trained in it or to a structured digital program, and we follow up on how it is going.

Medication has a place, usually for short periods or while CBT-I takes hold. Options include melatonin receptor agonists, orexin receptor antagonists, sedating antidepressants such as trazodone or mirtazapine, and the older benzodiazepines and Z-drugs. We are cautious with that last group in older adults because of falls and memory effects, and we do not use any of them as the first or only treatment.

Habits will not fix chronic insomnia alone, but no treatment works without them. A consistent schedule including weekends, no caffeine after early afternoon, no alcohol or large meals near bedtime, a cool dark quiet bedroom, and exercise earlier in the day. The habit CBT-I leans on most is leaving the bed when you cannot sleep rather than lying there awake.

A caution on sleep medications

Sleep medications can cause next-day drowsiness, memory lapses, and dependence, and stopping them abruptly can cause rebound insomnia. Use them only under medical guidance, and never with alcohol.

Sleep diary and pencil beside a pillow, lamp, and softly lit window. — Treatment addresses sleep habits and the medical or behavioral factors that keep insomnia going.

When to see a neurologist

Come in if the insomnia has lasted more than a few weeks, is affecting your daytime function or mood, or if you snore, gasp during sleep, or wake with headaches, which point toward sleep apnea. The same goes for restless legs in the evening, which point toward restless legs syndrome, and for any concern about the sleep medications you are already on.

A visit with Dr. Achillefs Ntranos, MD is 60 minutes, in person in Beverly Hills or West Los Angeles or by video anywhere in California. We go through the sleep history and diary, review every medication, screen for apnea, restless legs, mood, and pain, and examine you. You leave with a written plan. Book a visit or call (310) 774-7025.