Complementary and alternative approaches
European guidelines for diagnosing and treating insomnia12 do not recommend Valerian and other
phytotherapeutics, acupuncture, aromatherapy, and foot reflexology to
treat insomnia because of poor evidence. Notably, these approaches and
products are popular worldwide and have been increasingly studied over
the past two decades to treat sleep disorders.
Light therapy is the use of light in the treatment of physical or
mental illnesses. When natural sunlight is not appropriate, light
therapy boxes mimicking outdoor light might provide an alternative to
adjust normal circadian rhythm. The fact that light inhibits the
secretion of melatonin and that the hypothalamus through the
retinohypothalamic tract controls circadian rhythms provides better
insight into how light therapy can be used to treat sleep
disorders.60,61 In studies of insomnia therapy, the
mean reported light intensity was 4800 lux.62 With
coauthors in their systematic review with meta-analysis, Van Maanen
reported light therapy to be effective for insomnia symptoms and
recommend it as a complementary method to insomnia
management.62 On the other hand, light therapy can be
questionable in patients with photosensitivity and epilepsy.
Music therapy is the therapeutic use of music to promote
patients’ mental and bodily health. Listening to music is a complicated
process accompanied by the activation of different brain parts with a
complex response, e.g., cognitive and emotional. Särkämö and colleagues,
in poststroke patients listening to music of their own choice, reported
mood improvement and cognitive enhancement.63 Nilsson
documented stress reduction in patients who underwent cardiac surgery
after 30 minutes of listening to soft and relaxing melodies with a
volume of 50 to 60 dB.64 In their systematic review
from 2017, Feng et al. documented that listening to relaxing music
improves sleep onset latency and overall sleep quality in primary
insomniacs.65
Aromatherapy is based on the usage of concentrated essential oils
extracted from fragrant floral parts to improve mental and physical
health. Aromatherapy is usually administered by either inhalation or
skin application.66 A possible explanation for
aromatherapy’s efficacy ranges from subjective psychological to direct
biological action.67 Some essential oils contain
terpenes that cross the blood-brain barrier and possess cholinergic
activity or act on gamma-aminobutyric acid
receptors.68 Certain odors, e.g., linalool and linalyl
acetate extracted from lavender, may induce sedation and
relaxation.69 In their systematic review from 2019,
Lin and coauthors also highlighted the results’ limitations and
documented that aromatherapy can be effectively used to improve sleep
quality.70 The study mentioned above is in line with
Hwang and colleagues’ previously published work, which documented
aromatic oils extracted from lavender and bergamot to be most commonly
studied.71
Massage is a thousands of years old technique involving
mechanical contact on the patient’s body, commonly used in medicine,
sports-related regeneration, and wellness. More than one hundred massage
types are known. In the literature, the influence of massage therapy on
the improvement of depression and anxiety was
documented.72 A possible massage therapy mechanism for
stress relief is decreased cortisol levels and an increase in active
neurotransmitters, such as serotonin and dopamine 73Hachul and colleagues reported improved sleep in postmenopausal women
with insomnia symptoms after massage therapy.74
Acupuncture and acupressure arise from traditional Chinese
medicine, characterized by the insertion of metallic needles into or
through the skin or applying mechanical pressure at specific sites. The
techniques mentioned above are believed to restore the proper flow of
vital energy, known as qi. The study by Jinhuan and coauthors has shed
more light on the effects of acupuncture for insomnia. They analyzed
fifteen studies involving 1108 patients and found acupuncture superior
to placebo in treating insomnia.75 On the other hand,
in 2019, He and coworkers published an overview of 34 systematic reviews
assessing acupuncture to treat insomnia. They recommended a cautious
interpretation of the promising results, as the included studies’
quality was generally low.76 Regarding existing
evidence of the acupressure effect on sleep quality, one systematic
review with meta-analysis reported an improvement in the Pittsburgh
Sleep Quality index compared with sham treatment. However, the authors
also identified a high risk of bias due to the absence of blinding
patients.77
Herbal medicine represents a commonly used
complementary/alternative approach to health promotion or disease
treatment. It refers to the utilization of plants or herbal nutritional
supplements for therapeutic purposes. Forms in which herbs can be
administered usually comprise herbal teas or plant extracts. Herbal
dietary supplements are widely used worldwide. E.g., up to one-quarter
of adults in the US report the use of an herb to treat a medical
condition.78 Some empirical studies explain the
possible sedative-hypnotic effect of some medical plants via interaction
with the neurotransmitter gamma amino-butyric acid and its
receptors.79 In 2015, Ni, with coauthors in their
systematic review with meta-analysis of RCT’s found Chinese herbal
medicine (CHM) superior to placebo with respect to its effect on
selected sleep quality parameters. However, due to heterogeneity, the
typical effect of CHM for insomnia could not be determined. As such, the
original studies’ overall poor quality requires a cautious
interpretation of the results.80 One of the most
commonly used herbal medicines for insomnia is Valeriana officinalis. In
a recent study, Shinjyo and colleagues, in their systematic review with
meta-analysis, concluded that valerian root could be a safe and useful
herb to treat sleep problems. Notably, they also reported no severe
adverse events associated with valerian intake. Of note, ’drinking a tea
ritual’ before bed can help relieve stress and promote restorative
sleep.