{{cs1 config|name-list-style=vanc}} {{Infobox medical condition | name = Terminal insomnia | synonym = Sleep maintenance insomnia, nocturnal awakenings, middle-of-the-night awakenings, middle insomnia | image = | image_size = | alt = | caption = | pronounce = | specialty = Sleep medicine | complications = | onset = | duration = | types = | causes = | risks = | diagnosis = | differential = | prevention = | treatment = | medication = | prognosis = | frequency = | deaths = }} '''Middle-of-the-night insomnia''', or '''sleep maintenance insomnia''', also called '''terminal insomnia''' in contrast with "initial insomnia", is characterized by having difficulty returning to sleep after waking up during the night or very early in the morning. Initial or "sleep-onset" insomnia consists of having difficulty falling asleep at the beginning of sleep.

The disrupted sleep patterns caused by middle-of-the-night insomnia make many sufferers of the condition complain of fatigue the following day. Excessive daytime sleepiness is reported nearly two times higher by individuals with nocturnal awakenings than by people who sleep through the night.<ref name="JPR">{{cite journal |title=Nocturnal awakenings and comorbid disorders in the American general population | journal = Journal of Psychiatric Research |doi=10.1016/j.jpsychires.2008.02.001 |pmid=18374943 |volume=43 |issue=1 |pages=48–54 |year=2008 |vauthors=Ohayon MM}}</ref>

Sleep research conducted in the 1990s showed that such waking up during the night may be a natural sleep pattern, rather than a form of insomnia.<ref name="Live Science">{{cite web|last=Wolchover|first=Natalie|title=Busting the 8-Hour Sleep Myth: Why You Should Wake Up in the Night|url=http://www.livescience.com/12891-natural-sleep.html|work=Live Science|date=16 February 2011 |accessdate=27 May 2011}}</ref> If interrupted sleep (called "biphasic sleeping" or "bimodal sleep") is perceived as normal and not referred to as "insomnia", less distress is caused and a return to sleep usually occurs after about one hour.<ref>{{Cite news | url=https://www.bbc.com/news/magazine-16964783 | title=The myth of the eight-hour sleep| work=BBC News| date=2012-02-22| last1=Hegarty| first1=Stephanie}}</ref>

==Causes== * Pain * Pregnancy * Anxiety * Difficulty breathing / sleep apnea * Urge to urinate or defecate * Hunger or thirst * Illness * Shift work * Erratic sleep schedule<ref name="HPP">{{cite web |url=http://www.druglib.com/abstract/ro/roth-t_hum-psychopharmacol_20080100.html |title="Daytime pharmacodynamic and pharmacokinetic evaluation of low-dose sublingual transmucosal zolpidem hemitartrate"- Human Psychopharmacology: Clinical and Experimental, 2008;23(1):13-20, Thomas Roth, David Mayleben, Bruce C. Corser, Nikhilesh N. Singh |accessdate=2008-05-27 |website=}}</ref>

Nocturnal awakenings are more common in older patients and have been associated with depressive disorders, chronic pain, obstructive sleep apnea, obesity, alcohol consumption, hypertension, gastroesophageal reflux disease, heart disease, menopause, prostate problems, and bipolar disorders.<ref name="HPP"/> Gastro-intestinal discomfort arising from food that has not been fully cooked, is also a contributor to middle of the night insomnia. Nocturnal awakenings can be mistaken as shift work disorder.

==Treatment== Middle-of-the-night insomnia is often treated with medication, although currently Intermezzo (zolpidem tartrate sublingual tablets) is the only Food and Drug Administration-approved medication specifically for treating MOTN awakening.<ref>{{Cite web|title=FDA approves first insomnia drug for middle-of-the-night waking followed by difficulty returning to sleep|work=Food and Drug Administration|date=2012-11-23|url=https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm281013.htm|archive-url=https://web.archive.org/web/20111124151448/http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm281013.htm|url-status=dead|archive-date=November 24, 2011|accessdate=2012-11-27}}</ref> Some studies have shown that zaleplon, which has a short elimination half-life of about 1 hour, may be suitable for middle-of-the-night administration because it does not impair next-day performance.<ref name="pmid30058034">{{cite journal |vauthors=Abad VC, Guilleminault C |title=Insomnia in Elderly Patients: Recommendations for Pharmacological Management |journal=Drugs & Aging |volume=35 |issue=9 |pages=791–817 |date=September 2018 |pmid=30058034 |doi=10.1007/s40266-018-0569-8 |s2cid=51866276 |url=}}</ref><ref name="Super 2012">{{cite book |vauthors=Super ER, Johnson KP |title=Therapy in Sleep Medicine |chapter=Sleep Pharmacotherapeutics for Pediatric Insomnia |publisher=Elsevier |year=2012 |doi=10.1016/b978-1-4377-1703-7.10036-2 |pages=457–464 |isbn=978-1-4377-1703-7 |quote=Zaleplon (Sonata) is FDA approved for the short-term treatment of insomnia in adults. It has a very short half-life of 1 hour, making it particularly effective for initial insomnia. It also has a unique role as an as-needed medicine for middle-of-the-night insomnia.}}</ref><ref name="Bhandari 2020">{{cite book |vauthors =Bhandari P, Sapra A |chapter=Zaleplon |date=2023 |chapter-url=https://www.ncbi.nlm.nih.gov/books/NBK551571/ |title=StatPearls |pmid=31855398 |access-date=2023-11-14 |quote=Several other studies have also confirmed that zaleplon has little or no residual effects the following morning, even when taken during the middle of the night for the inability to go back to sleep.}}</ref><ref>{{cite journal | pmid = 17557470 | volume=2 | issue=4 | title=Sleep and residual sedation after administration of zaleplon, zolpidem, and placebo during experimental middle-of-the-night awakening | date=October 2006 | journal=J Clin Sleep Med | pages=417–23 | vauthors=Zammit GK, Corser B, Doghramji K ''et al''| doi=10.5664/jcsm.26657 | doi-access=free }}</ref><ref>{{cite journal | pmid = 18690916 | volume=1 | issue=1 | title=Hypnotics and driving safety: meta-analyses of randomized controlled trials applying the on-the-road driving test | date=January 2006 | journal=Curr Drug Saf | pages=63–71 | vauthors=Verster JC, Veldhuijzen DS, Patat A, Olivier B, Volkerts ER | doi=10.2174/157488606775252674| hdl=1874/19756 | s2cid=34334648 | hdl-access=free }}</ref><ref>{{cite journal |vauthors=Stone BM, Turner C, Mills SL, etal |title=Noise-induced sleep maintenance insomnia: hypnotic and residual effects of zaleplon |journal=Br J Clin Pharmacol |volume=53 |issue=2 |pages=196–202 |date=February 2002 |pmid=11851645 |pmc=1874295 |doi= 10.1046/j.-5251.2001.01520.x}}{{cbignore|bot=medic}}</ref> Because most medications usually require 6–8 hours of sleep to avoid lingering effects the next day, these are often used every night at bedtime to prevent awakenings.<ref>{{cite web |url=http://www.med.upenn.edu/uep/user_documents/dfd16.pdf |title="Nocturnal awakenings: a case study with decision points"- Journal of Family Practice, April 2008 |accessdate=2008-07-11 |url-status=dead |archiveurl=https://web.archive.org/web/20100714035316/http://www.med.upenn.edu/uep/user_documents/dfd16.pdf |archivedate=2010-07-14 }}</ref>

Sleep restriction therapy and stimulus control therapy as described in insomnia have shown significance in treating middle of night insomnia.<ref>{{Cite journal |last=Furukawa |first=Yuki |last2=Sakata |first2=Masatsugu |last3=Yamamoto |first3=Ryuichiro |last4=Nakajima |first4=Shun |last5=Kikuchi |first5=Shino |last6=Inoue |first6=Mari |last7=Ito |first7=Masami |last8=Noma |first8=Hiroku |last9=Takashina |first9=Hikari Nishimura |last10=Funada |first10=Satoshi |last11=Ostinelli |first11=Edoardo G. |last12=Furukawa |first12=Toshi A. |last13=Efthimiou |first13=Orestis |last14=Perlis |first14=Michael |date=2024-04-01 |title=Components and Delivery Formats of Cognitive Behavioral Therapy for Chronic Insomnia in Adults: A Systematic Review and Component Network Meta-Analysis |url=https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2814164 |journal=JAMA Psychiatry |language=en |volume=81 |issue=4 |pages=357 |doi=10.1001/jamapsychiatry.2023.5060 |issn=2168-622X |pmc=10794978 |pmid=38231522}}</ref>

==Prevalence== Waking up in the middle of the night, or nocturnal awakening, is the most frequently reported insomnia symptom, with approximately 35% of Americans over 18 reporting waking up three or more times per week.<ref name="JPR"/> Of those who experience nocturnal awakenings, 43% report difficulty in resuming sleep after waking, while over 90% report the condition persisting for more than six months. Greater than 50% contend with MOTN conditions for more than five years.

A 2008 "Sleep in America" poll conducted by the National Sleep Foundation found that 42% of respondents awakened during the night at least a few nights a week, and 29% said they woke up too early and couldn't get back to sleep.<ref>{{cite web|url=http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.3933533/ |title=2008 "Sleep in America" poll |accessdate=2008-07-10 |archiveurl=https://web.archive.org/web/20080703215357/http://www.sleepfoundation.org/site/c.huIXKjM0IxF/b.3933533/ |archivedate=2008-07-03 |url-status=dead }}</ref> Other clinical studies have reported between 25% and 35% of people experience nocturnal awakenings at least three nights a week.<ref>{{cite journal |title=Epidemiology of Insomnia: What We Know and What We Still Need to Learn|journal=Sleep Medicine Reviews|year= 2002|volume=6|issue=2|pages=97–111|author= Maurice M. Ohayon |doi=10.1053/smrv.2002.0186|pmid=12531146}}</ref>

==See also== *Polyphasic sleep

==References== {{reflist}}

{{DEFAULTSORT:Middle-Of-The-Night Insomnia}} Category:Insomnia