Waking up in the middle of the night and not being able to get back to sleep has a clinical name: sleep maintenance insomnia, also called middle insomnia. It is common. In a survey commissioned by the American Academy of Sleep Medicine, more than three in four US adults said they always, often or sometimes struggle to fall asleep or stay asleep.
It is more likely with age. Cleveland Clinic lists older age, being female and menopause-related hormone changes among the risk factors, and the usual triggers, from the timing of a glass of wine to a warm bedroom, can be changed.
Is it normal to wake up in the middle of the night?
Yes. Sleep runs in cycles, and a typical night holds four to six of them, each lasting about 80 to 100 minutes, according to the National Heart, Lung, and Blood Institute at the National Institutes of Health. People may wake briefly between cycles, the institute notes.
The difference is whether you drift straight back off. Seema Khosla, MD, a sleep medicine physician and medical director of the North Dakota Center for Sleep, said on NPR’s Life Kit podcast that waking at night only becomes an insomnia concern when it starts to affect how you function the next day.
Why does it happen around 3 a.m.?
- Lighter sleep later in the night. Deep sleep (the slow-wave stage) is packed into the early hours of sleep, and REM sleep, the dreaming stage, becomes more common later in the night, per the same NHLBI guide.
- Less sleep pressure. Alicia Roth, PhD, a behavioral sleep medicine psychologist at Cleveland Clinic in Cleveland, Ohio, explains that the body’s drive to sleep runs low partway through the night, after the first few hours have taken the edge off. Roth says this alone can cause middle-of-the-night waking.
- The morning rise in cortisol. Cortisol, a hormone involved in alertness and the stress response, starts its daily climb from around 2 to 3 a.m., writes Brian Meusborn, PA-C, a physician assistant at Texas Health Family Care in Flower Mound, Texas, for Texas Health Resources. He adds that the second half of the night shifts toward lighter stages that are easier to wake from, and for anyone who goes to bed between 10 p.m. and midnight, those lighter cycles fall close to 3 a.m.
That cortisol rise is normal, not a sign that something has gone wrong. In a University of Bristol study of 201 healthy adults aged 18 to 68, cortisol was already climbing in the hours before people woke up, and it did not spike because they woke, Sleep Review reported. The researchers, including co-lead author Stafford Lightman, PhD, a professor at Bristol Medical School in England, concluded the rise runs on the body clock.
What makes 3 a.m. wake-ups more likely?
- Alcohol. A review of 20 studies, published in the journal Alcoholism: Clinical & Experimental Research, found that alcohol helped people fall asleep faster at every dose tested but made sleep more broken during the later hours of the night, ScienceDaily reported. The Sleep Foundation’s alcohol guide notes that the liver clears roughly one drink an hour and suggests leaving three or more hours between the last drink and bedtime.
- Afternoon caffeine and late naps. Both weaken the sleep drive that carries you through the night, and so does going to bed earlier than your body is ready for, according to Roth at Cleveland Clinic.
- A warm room and a full bladder. Meusborn at Texas Health Resources recommends a bedroom between 60 and 67°F, easing off fluids in the two to three hours leading up to bedtime, and leaving three or more hours between a large meal and lights out.
- A long gap after dinner. Meusborn also suggests that an overnight dip in blood sugar can prompt cortisol release, especially after an early dinner. His fix is a small protein snack in the half hour to hour before sleep if that matches your pattern. This is one clinician’s view rather than a settled finding.
- Stress, pain and other health problems. Cleveland Clinic lists anxiety, depression, sleep apnea, chronic pain and needing to urinate often at night among the possible underlying causes of middle insomnia.
Why waking at night often starts in your 40s
Perimenopause, the years of hormonal change before periods stop for good, is one of the biggest drivers. Clinical psychologist Shelby Harris, who is board certified in behavioral sleep medicine and wrote The Women’s Guide to Overcoming Insomnia, said on the BetterSleep podcast that waking around 2 or 3 a.m. is one of the most common complaints she hears from women in their 40s and 50s. She explained that falling estrogen affects both sleep and temperature control, and that progesterone has a calming effect, so sleep can suffer when it dips.
Hot flashes are a measurable part of the picture. In a sleep lab study published in Fertility and Sterility, 34 perimenopausal women averaged 3.5 hot flashes a night, and about 69% of those hot flashes came with an awakening. That added up to roughly 17 minutes awake per night.
Wearable data points the same way. The Apple Women’s Health Study at the Harvard T.H. Chan School of Public Health tracked more than 300 women across menopause and found that 60% spent more time awake after falling asleep in the 18 months before their final period. The change was small: comparing the year before and the year after the final period, it worked out to about four extra minutes awake per eight-hour night, versus about one minute from two years of aging alone.
Age adds its own shift. Sleep also gets lighter with age, with less deep sleep, and the body clock shifts toward earlier bedtimes and wake-ups, Harvard Health Publishing reports. Kathryn Corelli, MD, an internist and menopause specialist at Brigham and Women’s Hospital in Boston, told the publication that people tend to need less sleep as they get older and often start waking earlier.
For night sweats, sleep writer and advocate Lindsay Scola suggested on another BetterSleep episode moisture-wicking pajamas and sheets, separate blankets from a partner, and a fan or cold pack within reach.
Why you wake at the same time every night
Waking at the same time each night is partly a matter of habit. Aric Prather, a professor and sleep scientist at the University of California, San Francisco, and author of The Sleep Prescription, explained on NPR’s Life Kit that waking, checking the clock and feeling your brain switch on can train the bed itself to become a cue for being awake. Repeat that enough times and the pattern sets in.
How to fall back asleep at 3 a.m.
The steps below run in order, from first waking to getting up.
- Leave the clock and phone alone. Knowing the time tends to start the mental math about how many hours are left. Chris Winter, MD, a double board-certified sleep specialist, told Tom’s Guide to keep the phone out of reach and skip the clock entirely. Turning the clock to face the wall is an easy way to stick to it.
- Slow your breathing. Cleveland Clinic lists 4-7-8 breathing as one of the relaxation methods that helps people with middle insomnia. Breathe in through the nose for a count of four, hold for seven, and breathe out slowly through the mouth for eight.
- Relax one muscle group at a time. Progressive muscle relaxation, also on Cleveland Clinic’s list, means tensing a group of muscles for a few seconds and then letting go, working from the feet up to the face.
- Give your mind something dull to do. Scola recommends cognitive shuffling, which means thinking of a word for each letter of the alphabet, or a slow body scan from the toes up. Both give racing thoughts a neutral place to go.
- Get up if it is not working. Prather suggests a limit of about 20 minutes awake in bed. Since checking the clock is off the table, estimate it. Winter suggests sitting somewhere dim and doing something calm, such as reading a paper book. If getting up feels like too much, Prather says even lying at the foot of the bed helps break the pattern.
- Write the worries down. For racing thoughts, Ravi Aysola, MD, a pulmonary and critical care physician and sleep expert at UCLA, said on NPR’s Life Kit to get out of bed and write the thoughts down on paper, then add a few things you are grateful for. Go back to bed when you feel sleepy, and keep it to the bed rather than the couch, Scola adds, so the bed stays the place for sleep.
If you get up in the dark, a low night-light in the hallway or bathroom keeps the light dim and the path safe.
Daytime habits that reduce night waking
- Schedule your worrying. On NPR’s Life Kit, Prather recommends scheduling a set worry period during the day, ideally writing the worries down, and host Andee Tagle suggests 10 to 20 minutes for it.
- Move caffeine earlier and keep naps short or skip them. Both protect the sleep drive Roth describes.
- Set a cutoff for alcohol, fluids and big meals. Use the three-hour guide for alcohol and meals, and two to three hours for fluids.
- Keep the bedroom cool. Aim for the 60 to 67°F range, and use breathable layers so you can adjust during the night.
- Go easy on the sleep tracker. On another Life Kit episode, Aysola described orthosomnia, anxiety driven by sleep-tracking data, and said the trouble starts with measurement that comes without guidance.
For a full wind-down routine, see what sleep experts do before bed.
When to talk to a doctor
The American Academy of Sleep Medicine defines chronic insomnia as trouble falling asleep, staying asleep or waking too early on three or more nights a week, for three months or longer. You do not need to wait that long to ask for help. Meusborn advises seeing a clinician if you wake on three nights a week or more, several weeks running, if you feel exhausted or impaired during the day, or if two to three weeks of better habits make no difference.
Some signs point to a different problem. Gasping or choking awake, or waking with chest pain, needs prompt attention, according to Meusborn. Harris adds that snoring, pauses in breathing and restless legs can all break up sleep and become more common with hormonal change, and she suggests looking for a board-certified sleep specialist who regularly treats your specific issue.
The first-line treatment for chronic insomnia is cognitive behavioral therapy for insomnia, or CBT-I. It identifies and addresses the patterns that affect sleep and includes breathing and relaxation techniques, and most people improve after four to eight sessions over six to eight weeks, according to Cleveland Clinic. In a Cleveland Clinic study of a six-week online CBT-I program, about three in four people who completed it saw meaningful, lasting improvement, which makes the online version worth asking about if in-person sessions are hard to fit in.
FAQ
Is waking up at 3 a.m. caused by cortisol?
Not on its own. Cortisol rises naturally in the early morning hours as part of the body clock, and the University of Bristol study found that rise happens before waking rather than because of it. Meusborn notes that high everyday stress can make that natural rise more likely to wake you.
Why does a glass of wine make me wake up in the night?
Alcohol makes it easier to fall asleep, but as it wears off in the early morning hours, sleep becomes lighter and more broken. The Sleep Foundation suggests a gap of three hours or more between the last drink and bedtime.
Should I stay in bed or get up?
Stay in bed and try the breathing and relaxation steps first. If sleep has not come back after what feels like 20 minutes, get up, keep the lights low and do something calm until you feel sleepy again.
Is it a sign of perimenopause?
It can be. Harris says shifting estrogen and progesterone, along with hot flashes, disrupt sleep in these years, and that waking around 2 or 3 a.m. is one of the most common complaints she hears from women in their 40s and 50s. A doctor can talk through symptoms and treatment options with you.
The bottom line
An occasional 3 a.m. wake-up is a normal part of how sleep works: lighter sleep, a lower sleep drive and a natural cortisol rise all meet in the early morning. The most useful change is also the simplest. Do not check the clock, breathe slowly, and if sleep has not returned in about 20 minutes, get up and read something dull in low light. If it is happening most nights for weeks, or you are tired all day, ask about CBT-I.
This article is for general information and is not medical advice. Talk to your doctor about any ongoing sleep problems.
