"I wake up at 3 a.m." — what do we look at first?

What follows combines several people's visits into one reconstructed account. It is not any one person's story, and anything that could identify someone has been removed.

How do people describe it when they come in?

They can fall asleep, but they wake up around 2 or 3 a.m. without fail, and then it takes a long time to get back to sleep. The time is almost always the same — that's the telltale sign.

Most people don't come in just to talk about sleep. They also mention that their neck and shoulders are always stiff, their stomach feels bloated, and they're tired during the day. So it's common for someone to come in for their lower back or neck, and for sleep to come up only when we ask.

Why is it the same time every night?

While you sleep, your body regulates its own temperature and blood sugar. In people whose regulation is running close to the limit, we think the body sends out an emergency signal at a certain point in the night and wakes them up.

If you stay tense all day, that state carries on into the night. We often compare it to sleeping with the lights on. At the time when you should be sinking into deep sleep, your body is still at work.

So rather than asking "What's keeping you from sleeping?", we first look for "What's keeping your body from resting at night?"

What do we look at?

We check your pulse and tongue, and press on your abdomen. We also check how stiff your neck and shoulders are and how you spend your days.

When we press on the abdomen, many people have a hard, tender spot below the breastbone or along the sides. When the body has been tense for a long time, those areas stiffen first.

We always check what medications you take, too. Quite a few people are on sleeping pills or anti-anxiety medication, and we don't tell them to stop.

How do we treat it?

We loosen the stiff neck and shoulders to ease the tension around the head, and use herbal medicine to help the body settle down at night.

There's an order to it. If your stomach is uncomfortable, we make your stomach comfortable first. When your digestive system keeps working, sleep becomes shallow. After that, we shift the focus to sleep.

We explain this order in advance, because the first prescription isn't a sleep remedy, and you may wonder, "Why isn't this medicine for sleep?"

How did people do?

For many, the number of times they wake up drops first. Next, it takes less time to fall back asleep after waking. The time they fall asleep is the last thing to change.

So we track progress by "How many times did you wake up?" rather than "What time did you fall asleep?" That's the one that moves first.

Some people see no change. If we don't find a direction after a few visits, we recommend other tests, such as a sleep study (polysomnography).

What are the limits of this approach?

Waking in the early morning has other causes too, such as sleep apnea, depression or medications. What we look at is just one of those paths.

One more thing: if you snore heavily or have been told you stop breathing in your sleep, get tested for that first.

If you have the same symptoms

1. Waking up at about the same time every night is a common pattern.
2. We don't look at sleep on its own — we look at your stomach, neck and shoulders, and daytime tension together.
3. If your stomach is uncomfortable, we deal with that first — the first prescription may not be a sleep remedy.
4. "How many times you woke up" changes before "what time you fell asleep."
5. If you snore heavily, a sleep apnea test comes first.

We start by sorting out what kind of insomnia it is. Not being able to fall asleep and waking up during the night point to different places to look.

If poor sleep is wearing down your days, come and see us. We'll start by sorting out whether you can't fall asleep or keep waking up. Each points to a different place to look.

Because there are many possible causes, progress differs from person to person, even with the same care.