Headache, health

Hormonal migraines

When I ask women in clinic what they think are their potential triggers approximately 75% say, “hormones” and they often open consultations with the phrase:

“I definitely have menstrual migraine”.

The majority however, do not.  Changes in hormone levels are a potent trigger for migraine attacks but only less 10% of suffers are classified as having “menstrual migraine”.  This can mean that any woman who suffers with migraine has the potential to have an attack around menstruation or at other points in the cycle where hormone levels fluctuate.  This can explain why puberty and the peri-menopausal phases can be times where women experience increasing numbers of attacks.

The hormones

The menstrual cycle is ruled by a complex of hormones which include oestrogen and progesterone as well as other substances which continuously form a feedback loop between the brain (pituitary anad hypothalamus glands) and the reproductive organs. The cycle essentially exists to ensure the body is ready for pregnancy to occur: 

  • At the beginning of the cycle the oestrogen levels begin to rise causing the the lining of the womb to build up as egg development is stimulated in the ovary and subsequently released (ovulation).  
  • In the second half of the cycle, the progestogen levels start to rise to ensure the lining stays thick in order to receive the fertilised egg for implantation and embryo development.
  • If fertilisation does not occur, the egg is reabsorbed and the oestrogen and progesterone levels begin to fall prior to menstruation.

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What are menstrual migraines?

Menstrual migraines are typically migraine without aura that occurs only during the phase of menstruation (that is between two days before a period and in the first three days).  This type of migraine can be more prolonged than other forms.

These are thought to be triggered by the drop in oestrogen levels which occurs approximately 48 hours before menstruation or due to the release of a substance called prostaglandin during early menstruation.  

The only way to establish whether or not this type of migraine occurs is to keep a migraine diary and tracking it with your periods. 

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Can hormones still trigger attacks if this isn’t the case?

As I’ve said, many women who suffer with migraine attacks find they are hormonally sensitive and so more likely to have attacks at some point around their period.  For the sake of semantics these migraine attacks are “menstrually associated migraine”.    People often find that they have more attacks during phases where they have a sudden surge of hormones such as puberty, pregnancy, breast feeding and around the menopause.  

How can these be treated?

This depends on whether you purely have menstrual migraine or if you have menstrually associated migraine and what stage of life you are at.  Options include:

  • Hormonal control which can be further divided into:
    • The Pill.  This can be an option for people with any type of hormonally sensitive migraine (although it is worth noting that the oestrogen component of the combined pill can make some people suffer more frequent attacks).  With menstrual migraine some people benefit from “tricycling” there pill where they take it almost continually.  Others find benefit from stabilising their hormone levels with the progestogen only pill.
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    • Oestrogen.  In menstrual migraine some people can benefit from supplementing their falling levels with oestrogen applied by patch or gel for a week around their period. 
    • HRT can be beneficial in the perimenopause but I will discuss this in more detail in another article…
    • Mefanamic acid.  People who have heavy painful periods may be familiar with this medication: it is in the same family of medications as ibuprofen (NSAIDs) and is thought to help in menstrual migraine by reducing the prostaglandin release which may contribute to menstrual migraine in some cases.
    • Frovatriptan.  This is a long-acting triptan which can be used on a regular basis around the expected migraine time to prevent attacks.  Although we usually advise against using triptans on a regular basis, taking Frovatriptan twice a day from two days before the expected attack for 6 days seems to help with menstrual migraine in some cases.
    • Preventative.  Any formal preventative has the capacity to help with menstrually associated migraine and severe menstrual migraine.  

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Are there any natural ways of managing this?

Hopefully that’s given a brief overview about hormonal migraine.  Like with all types of migraine there is no “one size fits all” answer and most people have very individual and varying triggers, one of which is often hormones.  I will discuss migraine in pregnancy and perimenopausal migraine in more detail later on…

health

Anxiety and Depression

Are we all getting more depressed? 

Depression is the third most common reason for people to visit the GP, with anxiety being the most common psychiatric disorder people suffer.  It’s difficult for people to unpick whether they’re anxious or depressed because they often co-exist.  Like with most health problems there’s a scale: some people suffer with mild mood disorders and require a bit of support, but for others anxiety and depression can be severe, life-altering and, in its extreme fatal.  

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How are anxiety and depression defined?

They are officially two separate conditions:

Anxiety usually refers to generalised anxiety disorder (GAD) which is one or a range of anxiety disorders which can also include more specific variants such as obsessive compulsive disorder, social phobia, post-traumatic stress disorder and so on.

  • Someone who suffers which GAD is described as suffering uncontrollable and widespread worry with the presence of physical and psychological symptoms.

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  • These symptoms can include (but are not limited to):
    • fast heart rate
    • awareness of thumping heart beat (palpitations)
    • sweating
    • chest pain
    • dry mouth
    • shakes or tremors
    • rapid breathing
    • dizziness or light-headedness
    • feeling sick (nausea)

Depression is the feeling of low mood or inability to take pleasure in things which is persistent and interferes with your normal life.  It is completely normal to have variations in mood and feel really low from time to time, particularly at times of stress, or as a reaction to a life-event, but if the feeling stays for at least two weeks and is accompanied by other physical and behavioural symptoms it could be depression.

  • Like with anxiety, depression can give a range of symptoms.  These include:
    • Difficulty sleeping: typically waking up early in the morning, but sleeping too much can be an issue.
    • Difficulty concentrating
    • Feeling tired or lethargic
    • Change in appetite: like with sleep this can go either way with people not eating or overeating
    • Thoughts or death and dying: this is not always as extreme as wanting to end your own life but commonly in mild to moderate depression a feeling that other people would be better off without you or that life “isn’t worth living”.  In more severe cases this can develop into thoughts of or even plans for suicide.
    • Feeling agitate or conversely slowing down of movements.

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Who is likely to suffer?

Depression can affect anyone.  Some people seem more likely to suffer from it than others but the mechanism which drives this is not fully understood.  Certain life-situations make people more likely to suffer (such as unemployment, marital breakdowns and money trouble) but undoubtedly genetics, upbringing and personality play a part too.  Having any form of chronic illness such as diabetes or heart trouble increases peoples risk.

It’s a slightly different picture for anxiety.  Although it too is a complex disorder certain characteristics make people more likely to suffer:

  • being female
  • experiencing difficulties in childhood (bullying, abuse etc)
  • having lifestyle stressors such as unemployment or dissatisfaction with work, money troubles, physical or emotional pain (such as from a a traumatic event)
  • Dependence to drugs or alcohol: this can be the cause or can just augment existing anxiety
  • Long term illnesses

Are we more depressed and anxious?

The answer to the question I asked at the beginning of the article is not straight forward.  If we look at the stats the suicide rates these tend to fluctuate year on year with the latest data showing this has fallen in the UK.  But the concerning feature that is often highlighted in the media is the high rate of male suicide which has accounted for 75% of all suicide since the 1990s.  As I said above, this is not because men are more likely to suffer from depression or even severe depression then women but it is thought that men are less likely to seek help about it.  This has prompted lots of campaigning to ensure men recognise the signs of depression, and know where to go for help.

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The other thing we look at is numbers of people seeing their GP about anxiety or depression.  These numbers are high but this may be because we are more willing to recognise it as a problem now than in the past.  There is still a stigma attached and people will wait 6-8 years to seek help for anxiety and depression.

What can we do about it?

There are a number of tests or questionaires you can do on the internet which ask how stressed, anxious or depressed you are but truthfully if you feel you are anxious or depressed and it is interfering with your life you should go an see your GP.  It is important to see a GP if you have any thoughts of suicide.  A lot of people worry that they’re “wasting the GPs time” or that they may just be “fobbed off” with tablets. 

Generally speaking there is no “one-size fits all” approach to anxiety and depression and discussing your problems with your GP can help to identify which treatment route would be best.  There are some avenues you can explore yourself:

  • Mindfullness: this essentially means being more aware of our surroundings and our own thoughts and feelings.  It’s the basis behind a lot of meditation and can help to treat anxiety and depression as well as being more aware of developing symptoms.  Some people use apps such as headspace or calm or more information can be accessed here.

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  • Exercise is also helpful in treating anxiety and depression.  This is due to the chemicals released during exercise (endorphins).  There is also emerging evidence that exercising regularly reduces the risk of future anxiety and depression at any age and although there was no specific “dose” suggested they advised a minimum of 150 hours of moderate to vigorous activity per week can reduce the risk of developing depression in the future by 10%.

The mainstay of treatment is counselling usually “talking therapy” using a method called cognitive behavioural therapy (CBT).  This type of therapy is useful for changing patterns of behaviour and thus reduces the symptoms of anxiety or depression.  CBT can be given as part of a group or individually, via computer programmes or, in some areas via Skype.  Most GP practices will have information on how to access this type, or other forms of counselling.

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Medication is still used, particularly for moderate to severe anxiety or depression.  It is important to realise that this is not a “magic bullet” but can help to stabilise things in order for people to be able to access therapy or other treatments.  There are lots of different types of medications used and there is a lot of overlap between the tablets used for both anxiety and depression (for example selective serotonin re-uptake inhibitors or SSRIs are commonly used for both anxiety and depression).  Generally speaking we expect people to be on these tablets in the short-term (6-12 months) but obviously some people will need longer term treatment.

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There are also tablets which can help with the symptoms of anxiety such as palpitations, nausea, sweating and chest pain.  Often beta-blockers such as propranolol are used.  These can be taken as and when to help with symptoms. There are not many side-effects but some people can experience dizziness, fatigue and vivid dreams   They are not suitable for asthmatics.

Suggested Links

If you need further advice please see:

Mind www.mind.org.uk 

The Calm Zone for men aged 18-35 http://www.thecalmzone.net/ 

Anxiety UK http://www.anxietyuk.org.uk/ 

Samaritans www.samaritans.org.uk 

Young Minds: support for young people and parents of those struggling with mental health issues https://youngminds.org.uk 

health

Irritable Bowel Syndrome

Cramping abdominal pains, bloating, diarrhoea or conversely bouts of constipation: these are all common symptoms of Irritable Bowel Syndrome (IBS).  It’s a pretty common problem thought to affect 10-15% of the population with only 10-20% of sufferers ever going to see their GP.  It’s far more likely to occur in women than men (2:1 ratio female to male sufferers) and commonly affects people in their 20s and 30s.

I’ve been driven to write about it because these are symptoms I see every day in General Practice and have personally suffered with and I’ve found that once it’s been diagnosed it can almost be… dismissed.

“It’s just IBS.  No need to worry”.

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Unfortunately there are studies which show that, although IBS doesn’t limit the length of peoples lives, the quality of the lives sufferers lead can be impaired causing psychological issues and financial losses through missed time at work.

Case: Laura

Last month my friend Laura started to develop severe cramps in her stomach.  She felt sick, bloated and she started having bouts of diarrhoea.  This was unusual for her: she’s very healthy and is rarely off work.  She’s also self-employed so any time she does need to take off is unpaid.  So she took some antacids and just powered through it.  Her pain continued.  It was so bad one night that she called 111 and was advised to go to A&E.  It was December and we were in the grips of yet another winter crisis for the NHS: the hospitals were full to the brim and the staff overworked.  They assessed her and told her it was probably gastritis.  Take some Omeprazole and see your GP.

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The pain continued.  She could barely eat over Christmas.  The pain was intermittent: she’d have periods of time where she thought she was better and go into work only for the pain to come on quickly and be so severe she’d have to return home.  She went to her GP who was very thorough.  She’d been diagnosed with IBS in her early 20s but never had any advice or testing for other things.  He wasn’t particularly happy about this “we should really make sure it isn’t any thing else”.  He arranged for a blood test (including a test for Coeliac’s Disease which is a gluten-allergy) and stool tests to check for a bug called H Pylori which can cause gastritis and another called a faecal calprotectin (to check for inflammation).

Off she went again, waiting for the results of the tests.  On my advice she’d started trying to track her symptoms to see if they were associated with any specific foods.  The blood tests and stool tests were all normal and she’d realised that her symptoms were worse every time she ate anything containing dairy.

What causes IBS?

Ok this is another syndrome where we don’t fully understand the processes involved but it is likely to be linked to a number of factors.

  • Genetics: no specific gene has been identified but twin studies suggest this has a role.

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  • Diet: this includes intolerances and sensitivity to certain foods and up to 90% of people suffering with IBS report certain food triggers
  • Infection: some people seem to develop IBS after gastroenteritis due to changes in the normal constituents of the gut due to the immune-response and normal bacteria which make up the gut flora.
  • Psychological factors: psychological stress due to anxiety or depression can alter the functioning of the bowel.  This is due to the presence of the “brain” around the gut (a complex neurological system which exists around the gastrointestinal system).

  • Medications: such as antibiotics

How is IBS diagnosed?

This is tricky.  There is no definitive test to confirm the presence of IBS: it’s made by looking at the pattern of symptoms and, if necessary, ruling out other causes.  Laura’s GP was correct: her symptoms were quite severe so it was worth making sure that she was tested appropriately.  But to be honest, this may not always be appropriate and it does depend on the pattern of symptoms and how certain the doctor seeing the patient is about the diagnosis.

I personally think a symptom diary can be invaluable.  Cutting out whole food groups at random always seems to be en vogue but it can lead to deficiencies which can endanger health and wellbeing.  Keeping a diary can help to identify any patterns of symptoms and make it easier to see if certain food groups trigger them.

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If testing is recommended I would always advise being checked for a gluten allergy (Coeliacs Disease) because it can cause similar symptoms.  Before this blood test is carried out you should make sure you’ve been eating wheat for at least 2 weeks otherwise it may be negative even if the disease exists.

Diet and lifestyle

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The most popular treatment option for sufferers of IBS (according to the BMJ) is the low FODMAP diet.  The term FODMAP relates to a new dietary class comprising of fermentable oligosaccharides, disaccharides, monosaccharides and polyols: a list of foods which ferment and thus are poorly absorbed.  This includes common foods such as:

  • Fruits (apples, cherries, peaches and nectarines)
  • Artificial sweeteners (sorbitol, xylitol and mannitol)
  • Vegetables and legumes (including broccoli, Brussels sprouts, cabbage and peas)
  • Most lactose-containing products

This diet is restrictive which can make it difficult to stick to.  Evidence from the trials shows that even short term adherence to the diet can lead to better gut health.  The longest duration of the diet in these trials seemed to be 6 weeks but even sticking to it for as little as 3 can be beneficial.

Ideally this diet should be adopted under the guidance of a dietician but there is a good factsheet from the IBS Network.

The NICE guidance also advises that probiotics purchased over the counter may have some benefit but the evidence from trials is limited and the probiotic should be tried for between 4-6 weeks.

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Exercise and regular physical activity are also advised in the management of IBS.  Theoretically, regular activity reduces bloating and gas retention and it is known that regular exercise reduces stress levels.  There have been some small trials which show that there was a significant reduction in IBS symptoms in patients who undertook a regular exercise programme compared to those who did no exercise.

Medications

There are no specific medications for IBS at present but the choice of medications should be based on the nature and severity of the symptoms.  The different medications can either be used in isolation or combination:

  • Antispasmodics such as Meberverine Hydrochloride or Peppermint Oil for abdominal cramps as required
  • Laxatives (but not Lactulose) for constipation symptoms.  The specific laxative Linaclotide can be prescribed for moderate-severe constipation in IBS if:
    • constipation has persisted for more than 1 year
    • all the other types of laxatives have been tried and failed
  • Anti-motility agents such as Loperamide for diarrhoea-type symptoms
  • Antidepressant medication can be tried if laxatives, antispasmodics or anti-motility agents have not worked.
    • Tricyclic Antidepressants (TCAs) such as Amitriptyline.  As with its use in migraine this would not be used to treat a suspected depression but for its neuropathic painkilling effects.
    • Selective Serotonin Re-uptake inhibitors (SSRIs) such as Citalopram or Fluoxetine if treatment with a TCA has been ineffective or poorly tolerated.

Cognitive Behavioural Therapy (CBT)

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Use of psychological therapies such as CBT has been advised for many years now, but uptake of such treatment is low, possibly because of the stigma associated with suffering with a “mental health disorder”.  The studies show that there can be some benefit from CBT in the initial stages following treatment but the benefits are vary according to the practitioner providing the treatment, the patients adherence to the treatment and the number of sessions which are provided.  This is still advised in the NICE guidance for IBS which does not respond to lifestyle changes or medications.

What next?

If none of the above is beneficial a referral to a gastroenterologist should be made to confirm whether or not IBS is indeed the diagnosis and for guidance on further management.

For more information please see:

The gut and liver disease charity CORE

The IBS Network

The Association of UK Dieticians factsheet on IBS and diet

health

Sleep

Insomnia affects one third of the UK population.  That’s a staggering number of people who suffer with difficulties sleeping.  Insomnia is defined as a difficulty getting to or sustaining sleep or not having good quality sleep all of which cause problems with daily functioning (namely concentration), low mood or day-time sleepiness.  In a nutshell it’s poor quality sleep and it has a big impact on people’s lives. It is thought that 10-50% of patients seen by GPs suffer with insomnia.  When you run a search using “insomnia” as your criteria a multitude of papers with slightly alarming titles come up:

“insomnia increases risk of heart attacks and stroke”

“insomnia is linked to risk of gestational diabetes”

“insomnia increases risk of developing asthma”

The list goes on.  So aside from affecting peoples psychological health and ability to function it is also linked to some pretty serious health problems.  Therefore, it’s a big deal.

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I’d agree with the statistic above: at least one patient a day visits me to talk about difficulties sleeping and more tend to mention it as an also-ran when discussing their other health problems.  It’s a diagnostic feature of depression (early-morning wakening) as well as a key feature of anxiety (waking up in the night, difficulty getting to sleep) but given the fact that lack of sleep causes mood problems which one comes first?  Or is it just a vicious cycle?  If the long-term effects are so serious what can we do about it?  And why are GPs so reluctant to prescribe sleeping pills?

Causes

The causes of insomnia are seemingly never-ending.  As mentioned above, the most common cause is anxiety and depression affecting almost half of patients experiencing sleep difficulties.  One cause is the presence of another medical condition such as asthma (if it’s badly controlled people tend to cough at night), thyroid disorders, pain due to joint disorders and heart problems which leads nicely to the next cause: medications that we give to treat these conditions.  Anti-depressants can cause sleep problems as can medications used to treat asthma such as salbutamol (commonly known as the reliever inhaler) and steroids which are used for the treatment of asthma and other inflammatory conditions.  As well as drugs we give, drugs (legal or otherwise) that people choose to take recreationally can also cause insomnia.  I include caffeine, alcohol and nicotine in this list.  Then there are the sleep disorders…

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Sleep Disorders

The most common of these is obstructive sleep apnoea.  This is a condition where the air-ways become blocked for a period of time.  The person appears to stop breathing and the lack of oxygen causes them to rouse partially so the airways can open again.  Understandably this does not result in a  great nights sleep and people can feel very drowsy during the day, falling asleep more readily than is normal.  This condition can be assessed before you go and see a doctor: snoring is an almost universal feature of this condition but partners often report frightening “pauses” in breath.  If this is the case it’s worth doing the Epworth Sleepiness Scale.  If the score is over 10 a referral should be made to a sleep clinic for further assessment.  Before it gets to the stage of requiring machines to help keep the airways open overnight (CPAP) or devices to wear in the mouth, life-style changes like losing weight, stopping smoking, reducing alcohol intake and stopping sedative treatment can help.

Changes in the normal sleep pattern (Circadian rhythm disorders) such as jet-lag and shift work can cause insomnia.  This type of problem is characterised by difficulty going to bed at the same time as normal people do a sleeping longer with marked difficulty in waking.  And the final sleep disorders are parasomnias a group of disorders with include restless leg syndrome and sleep walking.  If no cause can be found then a diagnosis of “Primary Insomnia” is reached.

What can you do about your sleep

I often feel patients are disappointed the first time they come to see me about their difficulty sleeping.  Unfortunately there is no “magic bullet” many people desire.  Once I’ve assessed their sleep pattern and tried to ascertain a cause I usually talk about “Sleep Hygiene”.  This is the phrase we use to describe measures that can be adopted to promote good sleep and incorporates changes to the sleep environment and behaviour.

  1. The first thing to do is establish a routine.  Go to bed and wake up at the same time, this avoids the problem of oversleeping and the body often responds well to routine.  Developing a relaxing bed-time ritual (i.e. a cup of herbal tea followed by some reading time) can be beneficial.
  2. Avoid caffeine or alcohol 6 hours before bedtime and consider cutting it out altogether.
  3. Avoid screen use (TV, computer, mobile phone) for up to an hour before bed.  The light-rays from these screens is very stimulating and can delay sleep initiation.

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  1. Don’t take naps during the day
  2. Avoid exercise within 4 hours of bedtime but do exercise regularly during the day.
  3. Only use the bedroom for sleep (or sexual activity).  So if you can’t fall asleep and you’ve been trying for more that 30 minutes get up.  Also try to avoid doing work in the bedroom.  You are less likely to associated the room as a place of rest and this can result in trouble sleeping.

It has been reported that 30% of people improved with the above measures alone.  If none of these measures are beneficial and the problem has persisted for 4 weeks or more it is worth completing a sleep diary and seeing your GP as they may want to check for some of the conditions listed above.

What about sleeping tablets

Once upon a time doctors gave out sleeping tablets like they were going out of fashion.  Now you may have noticed we’re a lot more cautious.  I am sure I’m not alone in feeling wretched when I hear someone sit down and say “I’d like to have some sleeping pills” largely because I know they are likely to leave disappointed.  It’s not because we’re being difficult or trying to deprive people of that elusive good nights sleep, but the risks of taking hypnotics or sleeping pills far out-weigh the benefits.  Simply put: they’re dangerous.  And most of them are highly addictive.  If people have tried all the measures above, and they understand that medications are to be used as the exception, not the rule, I will advise that they can try over the counter medications.  These include the natural supplements and antihistamines you can get from the chemist.  If they fail I may prescribe a very limited prescription for a dreaded “Z” drug.  They can be useful when used for less that 4 weeks but they do not guarantee good sleep quality so the effects of insomnia may remain despite taking these pills.  The other issue is stopping them, they are addictive as I’ve said before, but they also cause a rebound-insomnia when they are stopped.  Unusual sleep behaviours have been reported on hypnotics such as “sleep driving” without remembering the event.

What will work?

If insomnia is caused by an underlying condition such as asthma or a heart problem, treatment of this should resolve the sleep difficulties.  Reduction in caffeine or alcohol at night will help with issues caused by stimulation from these drugs.  There are sleep therapies which can help.  The first is Cognitive Behavioural Therapy (CBT) which is a psychological talking therapy aimed at changing behaviour patterns.  Practitioners often employ techniques such as bedtime restriction.  This works by looking at the time spent in bed versus the time spent asleep using a sleep diary and restricting the time allowed in bed to the time spent asleep (for example if someone’s diary indicates they spend 8 hours in bed but only 6 hours asleep they should only spend 6 hours in bed).  This is usually started as a trial for 2 weeks and can be a very simple yet effective way of managing the problem.  In fact, the evidence shows that cognitive behavioural interventions work better than sleeping tablets in most cases.

As I said at the beginning, problems with sleeping are common and there are a myriad of causes for them.  Reaching for sleeping tablets is rarely recommended and often employing some of the changes above can make a real difference to peoples quality of life.