A board-certified internist and expert in fatigue, sleep, and pain calls attention to disorders that can cause residual sleep dysfunction—even after a patient’s sleep apnea is treated with CPAP. In some cases, over-the-counter complementary and herbal therapies can complete the patient’s treatment regimen.

In addition to people simply not prioritizing sleep by making enough time for it, there are a host of other conditions that contribute to a worsening of sleep quality. Understanding these oft-overlooked conditions can dramatically improve a practitioner’s ability to help patients get well.

1. Fibromyalgia.


Though previously rare, fibromyalgia is a rising epidemic. It now has a prevalence of 2% of the population, with another 2% having milder forms. This syndrome represents an energy crisis—dropping energy production essentially trips a circuit breaker—which results in secondary hypothalamic dysfunction and chronic muscle shortening (it takes more energy for muscles to relax than to contract). The hypothalamus is a major control center for sleep, as well as hormonal and autonomic function.

Reasons for the marked increase in people suffering from energy deficits include:

  • diet micronutrients being lost by food processing, but leaving the calories. This is also why we see the paradoxical combination of obesity and malnutrition;
  • dwindling sleep time, in comparison to pre-light bulb eras. I’ve seen estimates that sleep time has been reduced on average from 9 hours to 6.75 hours—essentially a 30% pay cut for energy production;
  • the increasing speed and stress of modern life;
  • and chemicals in the environment that act as endocrine disruptors (per the World Health Organization1), resulting in abnormal hormonal function and secondary decreased energy production.

When people come in complaining of non-restorative sleep or difficulty falling and/or staying asleep, ask if they also have widespread pain and exhaustion. If yes, they likely have fibromyalgia.

Clinicians and patients can access a fibromyalgia screener on the website www.vitality101.com (see step 2 on the site). I founded this site more than a decade ago to provide free tools for people with fibromyalgia and other fatiguing disorders including disordered sleep. This screener is based on the American College of Rheumatology 2010 Amended Diagnostic Criteria.

If the patient does have fibromyalgia, then a study found that 91% of people improved with an average 90% increase in quality of life by using the S.H.I.N.E. Protocol (optimizing Sleep, Hormones, Immunity, Nutrition, and Exercise As Able; p<.0001 vs placebo).2 My site also provides feedback to determine how to use this protocol to optimize energy in each person, using a mix of natural and standard therapies (see step 3 on the website).

If you find fibromyalgia and give those impacted the information to understand and correct it, you will have happy and appreciative patients.

2. Periodic limb movement disorder (PLMD) and restless legs syndrome (RLS).


Research has shown that supplementing with iron helps decrease symptoms of periodic limb movement disorder and restless legs syndrome if the person’s ferritin level is under 60.3

Supplementing with magnesium 200 mg at bedtime and optimizing thyroid function even if the thyroid blood tests are “normal” will also decrease RLS and PLMD symptoms and help sleep.4 It is important to understand what the normal range means on these blood tests. Generally, it has little to do with health or symptom manifestation. “Normal” is derived by applying two standard deviations; that is, of 100 people, the highest and lowest 2.5% of the population are defined as “abnormal.” To use an analogy to shoe size, this would mean “normal” shoes are sizes 6 to 13. But, of course, just because your shoe size is in this normal range does not mean that a size 6 shoe will be comfortable. Similarly, even if a person’s thyroid level is in the “normal” range, that does not necessarily mean their thyroid level is adequate. If the person reports being tired, achy, or cold intolerant or if they are experiencing weight gain, restless legs syndrome-like symptoms,5 unexplained infertility, constipation, or any two to three symptoms suggestive of low thyroid, with a free thyroxine (T4) in the lowest 25th percentile (a normal or even low thyroid-stimulating hormone, or TSH, is unreliable), a trial of thyroid hormone to see if the patient clinically improves is warranted.

3. Fungal overgrowth in the sinuses causing sleep-disordered breathing.


In the absence of overt immunoglobulin E-mediated inhalant allergies, the most common cause of chronic nasal congestion and secondary upper airway resistance syndrome (UARS) is fungal overgrowth in the sinuses. Two Mayo Clinic studies have shown fungi to be the cause for over 90% of chronic sinusitis.6-7 My clinical experience finds with the prescription antifungal Diflucan (fluconazole) 200 mg a day for 6 weeks plus the antifungal herbal caprylic acid (I recommend Caprylex by Douglas Laboratories) and a compounded prescription nose spray with Bactroban (mupirocin)-xylitol-low dose cortisol-antifungal sold as “Sinusitis Nose Spray” by ITC Compounding Pharmacy, the nasal congestion and UARS resolve.

If fatigue and low blood pressure symptoms persist once the nasal congestion resolves, then the person will often also have the aforementioned fibromyalgia or chronic fatigue syndrome, in which case I recommend the S.H.I.N.E. Protocol approach to recover.

4. Sleep-onset and sleep maintenance insomnia.


For those with insomnia, it is important to divide them into those with difficulty with sleep onset versus maintaining sleep. From a complementary medicine point of view, common causes for difficulty with sleep onset include:

  • adrenal cortisol levels being too high at bedtime. Most people run morning cortisol levels of about 18 µg/dL. This needs to come down under 2 µg/dL for people to initiate sleep. Ask the patient if their mind is wide awake at bedtime or test salivary cortisol level at bedtime. To resolve, I find a mix of phosphatidylserine and ashwagandha 1 to 2 hours before bedtime will usually take care of this problem (I recommend Enzymatic Therapy’s “Sleep Tonight”). Often the same people will find that their blood sugar drops during the night, causing them to wake up (sometimes with a sweat) around 2 AM. Simply giving a 1-oz protein snack at bedtime, such as a hard-boiled egg, cheese, or meat, can be helpful.
  • just like children need a quiet time routine to settle down in the evening to ease into sleep, adults are no different. It is unreasonable to expect the body to shift from sympathetic to parasympathetic mode without this.

    Jacob Teitelbaum, MD

    Jacob Teitelbaum, MD

Once these two factors have been addressed, along with other sleep hygiene issues, herbal remedies can be used to help with both sleep initiation and maintenance. My two recommendations are Enzymatic Therapy’s Revitalizing Sleep Formula, which is a mix of valerian, passionflower, 5 HTP, theanine, lemon balm, and hops that increases in effect over 6 weeks. And EuroPharma’s Terrific Zzzz, which is a mix of essential oils including mandarin zest oil, lemon balm, ravintsara, and lavender.

I do sell these supplements on my site www.endfatigue.com, but I do not accept money from any pharmaceutical or supplement companies; the supplements are also available at most health food stores. As with any herbal, caution should be used when the patient is also on warfarin.

By using the best of standard and complementary therapies, you’ll find that people can have their restorative sleep…restored!

Jacob Teitelbaum, MD, is a board-certified internist and integrative medical expert. He is the author of the best-selling From Fatigued to Fantastic!; Pain Free 1-2-3; The Complete Guide to Beating Sugar Addiction; Real Cause, Real Cure; The Fatigue and Fibromyalgia Solution; and the free smart phone app Cures A-Z. He is the lead author of 4 studies on effective treatment for fibromyalgia and chronic fatigue syndrome and a study on treatment of autism using NAET (Nambudripad’s Allergy Elimination Techniques).


1. World Health Organization. Children’s environmental health: Endocrine Disrupting Chemicals (EDCs). ND. Available at www.who.int/ceh/risks/cehemerging2/en.

2. Teitelbaum JE, Bird B, Greenfield RM, Weiss A, Muenz L, Gould L. Effective treatment of chronic fatigue syndrome and fibromyalgia—a randomized, double-blind, placebo-controlled, intent-to-treat study. Journal of Chronic Fatigue Syndrome. 2011;8(2):3-15.

3. Wang J, O’Reilly B, Venkataraman R, et al. Efficacy of oral iron in patients with restless legs syndrome and a low-normal ferritin: A randomized, double-blind, placebo-controlled study. Sleep Med. 2009 Oct;10(9):973-5.

4. Hornyak M, Voderholzer U, Hohagen F, et al. Magnesium therapy for periodic leg movements-related insomnia and restless legs syndrome: an open pilot study. Sleep. 1998 Aug 1;21(5):501-5.

5. Tan EK, Ho SC, Eng P, et al. Restless legs symptoms in thyroid disorders. Parkinsonism Relat Disord. 2004 Mar;10(3):149-51.

6. Ponikau JU, Sherris DA, Kern EB, et al. The diagnosis and incidence of allergic fungal sinusitis. Mayo Clin Proc. 1999 Sep;74(9):877-84.

7. Cody DT 2nd, Neel HB, Ferreiro JA, et al. Allergic fungal sinusitis: the Mayo Clinic experience. Laryngoscope. 1994 Sep;104(9):1074-9.