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DESCRIPTION
Narcolepsy is a rare neurological disorder most characterized by Excessive Daytime Sleepiness (EDS), which is an overwhelming daytime drowsiness and sudden attacks of sleep. People with narcolepsy often find it difficult to stay awake for long periods of time, regardless of the circumstances. Narcolepsy can cause serious disruptions in daily routine. Narcolepsy is a chronic condition that does not go away completely.
The term narcolepsy derives from the French word narcolepsie created in 1880 by the French physician Jean-Baptiste-Édouard Gélineau (1859-1928) by combining the Greek "narke" (numbness, stupor) and "lepsis" (attack, seizure).
Narcolepsy is estimated, according to the American Sleep Association, to affect as many as 125,000 to 200,000 Americans, however, fewer than 50,000 have actually been diagnosed with the condition. It is estimated that as many as 3 million people worldwide are affected by narcolepsy. The prevalence of narcolepsy is about 1 per 2,000 persons in the United States, according to the National Institute of Neurological Disorders. However, in some countries (for example, Israel), the prevalence of narcolepsy is much lower (1 per 500,000) while in other countries (for example, Japan) it is much higher (1 per 600). It is as widespread as Parkinson's disease or multiple sclerosis and more prevalent than cystic fibrosis, but it is less well known. Narcolepsy is often mistaken for depression, epilepsy (seizure disorders), fainting, or the side effects of medications or other conditions that may cause abnormal sleep patterns. It can also be mistaken for poor sleeping habits or lack of sleep, recreational drug use, or laziness.
Narcolepsy can occur in both men and women at any age, although its symptoms are usually first noticed in teenagers or young adults. There is strong evidence that narcolepsy may run in families; 8 to 12 percent of people with narcolepsy have a close relative with this neurologic disorder. Narcolepsy has its typical onset in adolescence and young adulthood. There is an average 15-year delay between onset and correct diagnosis which may contribute substantially to the disabling features of the disorder. Cognitive, educational, occupational, and psychosocial problems associated with the excessive daytime sleepiness of narcolepsy have been documented. For these to occur in the crucial teen years when education, development of self-image, and development of occupational choice are taking place is especially damaging. While cognitive impairment does occur, it may only be a reflection of the excessive daytime somnolence.
It is a reason for patient visits to sleep disorder centers, and with its onset in adolescence, it is also a major cause of learning difficulty and absenteeism from school. Normal teenagers often already experience excessive daytime sleepiness because of a maturational increase in physiological sleep tendency accentuated by multiple educational and social pressures; this may be disabling with the addition of narcolepsy symptoms in susceptible teenagers. In clinical practice, the differentiation between narcolepsy and other conditions characterized by excessive somnolence may be difficult. Treatment options are currently limited. There is a paucity in the literature of controlled double-blind studies of possible effective drugs or other forms of therapy. Mechanisms of action of some of the few available therapeutic agents have been explored but detailed studies of mechanisms of action are needed before new classes of therapeutic agents can be developed.
Narcolepsy often remains undiagnosed or misdiagnosed for several years. It is an under diagnosed condition in the general population. This is partly because its severity varies from obvious to barely noticeable and health care providers do not consider the diagnosis of narcolepsy frequently enough. They may think of narcolepsy only in people who have the main symptom of excessive daytime sleepiness. Narcolepsy may not be considered in the evaluation of patients who come to practitioners complaining of fatigue, tiredness, or problems with concentration, attention, memory, and performance, and other illnesses (seizures, mental illness, etc.). Some people with narcolepsy do not suffer from loss of muscle control. Others may only feel sleepy in the evenings.
Besides the main characteristic of narcolepsy (excessive daytime sleepiness or sleep attacks), there are 4 other classic symptoms that define this syndrome:
- Cataplexy.
- Sleep paralysis.
- Hypnagogic (sleep-related) hallucinations.
- Automatic behavior.
Simply put, the brain does not pass through the normal stages of dozing and deep sleep but goes directly into (and out of) rapid eye movement (REM) sleep. This has several consequences:
- Night time sleep does not include as much deep sleep, so the brain tries to "catch up" during the day, hence EDS.
- People with narcolepsy may visibly fall asleep at unpredicted moments (such motions as head bobbing are common).
- People with narcolepsy fall quickly into what appears to be very deep sleep.
- They wake up suddenly and can be disoriented when they do (dizziness is a common occurrence).
- They have very vivid dreams, which they often remember in great detail.
- People with narcolepsy may dream even when they only fall asleep for a few seconds.
Although there's no cure for narcolepsy, medications and lifestyle changes can help you manage the symptoms. And talking to others - family, friends, employer, teachers - can help you cope better with narcolepsy.
SYMPTOMS
THE CLASSIC SYMPTOMS OF NARCOLEPSY
THE SLEEP ATTACK
The best known symptom of narcolepsy is excessive daytime sleepiness (EDS) and the sleep attack, even after adequate night time sleep and is present in 100 percent of patients with narcolepsy. A person with narcolepsy can suddenly become drowsy and fall into a sleep state with almost no warning whatsoever and may be physically irresistible. Sleep attacks can occur at any time, can happen in relaxed situations and also at inappropriate times and places, even in mid-conversation, as many as 10 times a day (even more, in some cases). Patients may fall asleep while watching TV, reading a book, driving, attending a meeting, or engaging in a conversation. These periods of sleep usually last only a matter of minutes, but in some cases sleep can continue for an hour or more. Afterward, the person may feel refreshed, yet he or she may fall asleep again in a few minutes or a few hours. Drowsiness may persist for prolonged periods of time. In addition, night time sleep may become fragmented with frequent awakenings. Patients may describe this symptom as being tired, fatigued, sleepy, feeling lazy, or having low energy.
Excessive daytime sleepiness is present throughout the day but the patient, with extreme effort, may be able to resist the sleepiness for some time. Finally, it becomes overwhelming and results in a sleep episode of varied duration (seconds to minutes). In addition to daytime sleepiness, repetitive, irresistible, and unintentional sleep attacks may occur throughout the day. Excessive daytime sleepiness usually impairs a patient's functioning because it reduces motivation and vigilance, interferes with concentration and memory, and increases irritability.
Normally, when an individual is awake, brain waves show a regular rhythm. When a person first falls asleep, the brain waves become slower and less regular.
While the sleep that results from narcolepsy looks like ordinary sleep, researchers have found at least one key difference. Normal sleep is a cyclical process that alternates between periods of rapid-eye-movement (REM) and non-rapid-eye-movement (NREM) sleep. During the NREM part of the cycle, the entire body slows down - pulse, breathing, blood pressure, and brain wave activity are all lowered. When the REM cycle begins, the body remains asleep, but the brain becomes significantly active; brain waves as recorded by an electroencephalograph (EEG) more closely resemble those of the waking brain. It is during REM sleep that most dreaming occurs.
In healthy individuals, sleep begins with the NREM phase. After 60 minutes or so of NREM sleep, REM sleep begins. A short time later, the entire cycle begins again, in a narcoleptic sleep attack, in contrast, researchers have found that REM sleep begins almost instantly, with no introductory NREM sleep. Also, some of the aspects of REM sleep that normally occur only during sleep - lack of muscular control, sleep paralysis, and vivid dreams - occur at other times in people with narcolepsy. The precise significance of this is not yet understood, but it does provide a useful diagnostic tool as well as a clue for researchers to pursue in trying to understand this mysterious disorder.
CATAPLEXY
The next classic symptom of narcolepsy is cataplexy. This is a type of paralysis or loss of muscle function - ranging from slight weakness, such as limpness at the neck or knees, sagging facial muscles, or inability to speak clearly, to complete body collapse - that usually occurs in response to some type of heightened emotion, such as anger, fear, laughter or excitement. Factors that contribute to the attacks of cataplexy include physical fatigue, stress, and sleeplessness. The individual does not lose consciousness, remaining conscious throughout the entire episode, but experiences a sudden and temporary loss of muscle tone. Often, only the legs and/or arms are affected. For example, your head may droop uncontrollably or your knees may suddenly buckle when you laugh. Severe attacks may result in a complete body collapse with a fall to the ground and a risk of injury. Milder forms are more common. These involve regional muscle groups and result in symptoms such as a drooping head, sagging jaw, slurred speech, buckling at the knees, or weakness in the arms. These episodes normally last for less than a minute (but can range from a few seconds to several minutes), and they seem to be most likely to occur if the person is surprised in some way. In some cases, cataplexy may resemble epileptic seizures. Some people with narcolepsy experience only one or two episodes of cataplexy a year, while others have numerous episodes each day. About 70 to 75 percent of people with narcolepsy experience cataplexy. The onset of cataplexy may coincide with the onset of excessive daytime sleepiness. However, cataplexy often develops years later. Therefore, the absence of cataplexy should not rule out the diagnosis of narcolepsy.
SLEEP PARALYSIS
Sleep paralysis is the another classic symptom of narcolepsy and may be present in up to 50 percent of patients with narcolepsy. This sleep paralysis mimics the type of temporary paralysis that normally occurs during rapid eye movement (REM) sleep, the period of sleep during which most dreaming occurs. This temporary immobility during REM sleep may prevent your body from acting out dream activity. Narcoleptic sleep paralysis occurs just as you are falling asleep, or as you are beginning to awaken, you try to move or say something but find that you cannot, even though you are fully conscious. This lasts for only a few seconds to minutes, but it can be frightening (but is not dangerous), especially the first time it happens. They can occur at the same time as hypnagogic (or hypnopompic) hallucinations. During sleep paralysis, breathing is maintained, although some patients may experience a frightening sensation of not being able to breath. You may be aware of the condition and have no difficulty recalling it afterward, even if you had no control over what was happening to you. These episodes usually end either on their own or when someone touches or speaks to you. Many health care providers feel that sleep paralysis is similar to cataplexy and to the state that accompanies REM sleep, in which motor activity is inhibited even though the brain is active. This phenomenon is not strictly limited to people with narcolepsy; many otherwise healthy people may experience it occasionally, especially in young adulthood.
SLEEP-RELATED HALLUCINATIONS (HYPNAGOGIC PHENOMENA)
Like sleep paralysis, sleep-related hallucinations - medically termed hypnagogic phenomena - usually occur just prior to sleep, or sometimes upon awakening. The affected individual may hear sounds that are not there and/or see illusions. These visual and auditory illusions as well as touch, balance, or movement and are very vivid, often frightening, dreamlike experiences that occur in a semi-awake state making the dream experience seem real. As a result, the patients may become fearful that they have or will develop a mental illness. This phenomenon also can occur in individuals who do not suffer from narcolepsy, particularly children. Hypnagogic hallucination may be present in up to 50 percent of patients with narcolepsy.
AUTOMATIC BEHAVIOR
Automatic behavior means that a person continues to function (talking, putting things away, etc.) during sleep episodes, but awakens with no memory of performing such activities and generally the person does not perform these tasks as well as he or she does when they are awake. A patient carries out certain actions without conscious awareness, often with the unusual use of words (irrelevant words, lapses in speech). This behavior occurs while the patient is fluctuating between sleep and wakefulness. It is estimated that up to 40 to 80 percent of people with narcolepsy experience automatic behavior during sleep episodes. People with narcolepsy may also act out their dreams at night by flailing their arms or kicking and screaming.
Other complaints associated with narcolepsy may include eye disturbances due to sleeplessness, such as double vision, blurred vision, or droopy eyelids.
Sleep paralysis and hypnagogic hallucinations also occur in people who do not have narcolepsy, but more frequently in people who are suffering from extreme lack of sleep. Cataplexy is generally considered to be unique to narcolepsy and is analogous to sleep paralysis in that the usually protective paralysis mechanism occurring during sleep is inappropriately activated. The opposite of this situation (failure to activate this protective paralysis) occurs in rapid eye movement behavior disorder.
In most cases, the first symptom of narcolepsy to appear is excessive and overwhelming daytime sleepiness. The other symptoms may begin alone or in combination months or years after the onset of the daytime naps. There are wide variations in the development, severity, and order of appearance of cataplexy, sleep paralysis, and hypnagogic hallucinations in individuals. The signs and symptoms of narcolepsy can begin anytime up to your 50s, but they most commonly begin between the ages of 10 and 25. Narcolepsy is chronic, which means signs and symptoms may vary in severity, but they never go away entirely.
Because the symptoms of narcolepsy vary from individual to individual (it is estimated that only 20 to 25 percent of people with narcolepsy experience all of the classic symptoms), this disorder is frequently misdiagnosed. The excessive daytime sleepiness generally persists throughout life, but sleep paralysis and hypnagogic hallucinations may not. Although these are the common symptoms of narcolepsy, many people with narcolepsy also suffer from insomnia for extended periods of time. The symptoms of narcolepsy, especially the excessive daytime sleepiness and cataplexy, often become severe enough to cause serious problems in a person's social, personal, and professional life.
There is strong evidence that narcolepsy may run in families (8 to 12 percent of people with narcolepsy have a close relative with the disorder). Further compounding the problem is the fact that other sleep disorders, such as sleep apnea, also can produce spells of marked daytime drowsiness. Narcolepsy is not a particularly dangerous problem, unless one experiences a sleep attack while operating a motor vehicle or other machinery. It can, however, be embarrassing and extremely inconvenient.
CAUSES
The exact cause or causes of this disorder are unknown, but it is believed that genetics may play a role. A larger influence may be a trigger, such as brain infection, head trauma, or brain tumors that leads to damage to certain brain cells important to sleep. These triggers may be behind some cases. It is known that narcolepsy is almost never the result of insomnia or sleep deprivation. There is currently no cure for this disorder, so the focus must be on treating the symptoms.
NORMAL SLEEP PATTERN VS NARCOLEPSY
The normal process of falling asleep begins with a phase called non-rapid eye movement (NREM) sleep. During this phase, your brain waves slow down considerably. After an hour or two of NREM sleep, your brain activity picks up again, and REM sleep begins. Most dreaming occurs during REM sleep.
In narcolepsy, however, you suddenly fall into REM sleep without first experiencing NREM sleep and at abnormal times, such as during the day. Also, some of the aspects of sleep that normally occur only during REM sleep, such as sudden lack of muscle tone, sleep paralysis and vivid dreams, occur at other times during sleep in people with narcolepsy.
THE ROLE OF BRAIN CHEMICALS
Hypocretin is an important chemical in your brain that helps regulate staying awake and keeps REM sleep stable and occurring at the appropriate time during sleep. The cells that make hypocretin are severely damaged in narcolepsy. Because the cells are damaged, hypocretin is found in low levels in people with narcolepsy - lowest of all in those who experience cataplexy.
Exactly what causes the damage to hypocretin cells is not known. But it is thought that there is probably some factor such as an infection and an abnormal immune response that leads to the damage. Certain genetic markers are also more common in people who develop narcolepsy. If another family member has narcolepsy, it is slightly more likely you could develop it.
Research continues to focus on whether an abnormal gene may be responsible for narcolepsy or if the body's immune system may be involved in mistakenly attacking hypocretin-producing cells in the brain.
The low levels of hypocretin may even lead to the development of a diagnostic test for narcolepsy. Hypocretin is normally present in spinal fluid of people without the disorder, but is present in only very low levels in the spinal fluid of people with narcolepsy.
RISK FACTORS
Narcolepsy may be more common in men than women and occurs in all racial and ethnic groups. However, rates do seem to vary by country. In the United States, about one in 2,000 people is affected by narcolepsy, while in Israel only one in 500,000 people has the disorder. Japan has the highest rate, affecting about one in 600 people. The condition may run in families. A small percentage of people with narcolepsy have a close relative with the disease.
While the cause of narcolepsy has not yet been determined, scientists have discovered conditions that may increase an individual's risk of having the disorder. Specifically, there appears to be a strong link between narcoleptic individuals and certain genetic conditions. One factor that may predispose an individual to narcolepsy involves an area of Chromosome 6 known as the HLA (human leukocyte antigen) complex. HLAs are genetically determined proteins on the surface of white blood cells. They are a part of the body's immune (defense) system. There appears to be a correlation between narcoleptic individuals and certain variations in HLA genes, although it is not required for the condition to occur. The finding of a very high HLA-association in narcolepsy led to the proposal that narcolepsy is an autoimmune disease, similar to other HLA-associated diseases such as multiple sclerosis and ankylosing spondylitis.
Certain variations in the HLA complex are thought to increase the risk of an autoimmune response to protein-producing neurons in the brain causing a loss of nerve cells in the brain in patients with narcolepsy. The protein produced, called hypocretin or orexin, is responsible for controlling appetite and sleep patterns. Individuals with narcolepsy often have reduced numbers of these protein-producing neurons in their brains. The environment (for example, infection or trauma) might trigger an autoimmune reaction where normal brain cells are attacked by the body's own immune system. As a result, the neurons are damaged and ultimately destroyed, and they and their neurotransmitter chemicals disappear. Whether narcolepsy is an autoimmune disease remains to be proven.
The neural control of normal sleep states and the relationship to narcolepsy are only partially understood. In humans, narcoleptic sleep is characterized by a tendency to go abruptly from a waking state to REM sleep with little or no intervening non-REM sleep. The changes in the motor and proprioceptive (the sense of the relative position of neighboring parts of the body) systems during REM sleep have been studied in both human and animal models. During normal REM sleep, spinal and brainstem alpha motor neurons (the large motor neurons of the brain stem and spinal cord) depolarize producing almost complete atonia (loss of muscle strength, extreme relaxation or paralysis) of skeletal muscles (the muscle we use for movement) via an inhibitory descending reticulospinal pathway. Acetylcholine may be one of the neurotransmitters involved in this pathway. In narcolepsy, the reflex inhibition of the motor system seen in cataplexy is believed identical to that seen in normal REM sleep.
In 2004 researchers in Australia induced narcolepsy-like symptoms in mice by injecting them with antibodies from narcoleptic humans. The research has been published in the Lancet providing strong evidence suggesting that some cases of narcolepsy might be caused by autoimmune disease.
Narcolepsy is strongly associated with HLA DQB1*0602 genotype. There is also an association with HLA DR2 and HLA DQ1. This may represent linkage disequilibrium (linkage disequilibrium is the non-random association of alleles at two or more loci, not necessarily on the same chromosome. It is not the same as linkage, which describes the association of two or more loci on a chromosome with limited recombination between them).
Despite the experimental evidence in human narcolepsy that there may be an inherited basis for at least some forms of narcolepsy, the mode of inheritance remains unknown.
Some cases are associated with genetic diseases such as Niemann-Pick disease or Prader-Willi syndrome.
COMPLICATIONS
Public misunderstanding of the condition. Narcolepsy may cause you to experience serious problems in both your professional and personal life. Others may perceive your condition as lazy, lethargic or rude. Your performance may suffer at school or work.
Interference with intimate relationships. Narcolepsy can affect intimate relationships. Extreme sleepiness may cause low sex drive or impotence, and people with narcolepsy may even fall asleep while making love. The problems caused by sexual dysfunction may be further complicated by emotional difficulties. Intense feelings, such as anger or joy, can trigger some signs of narcolepsy, causing affected people to withdraw from emotional interactions.
Physical harm. Sleep attacks may result in physical harm to people with narcolepsy. You are at increased risk of a car accident if you have an attack while driving. Your risk of cuts and burns is higher if you fall asleep while preparing food.
DIAGNOSIS & TREATMENT
DIAGNOSIS
Clinical evaluation includes a detailed medical history and physical examination by a health care provider. Your health care provider may make a preliminary diagnosis of narcolepsy based on your experience of both excessive daytime sleepiness and sudden loss of muscle tone (cataplexy). After an initial diagnosis, your health care provider may refer you to a sleep specialist for more evaluation.
Diagnosis is relatively easy when all the symptoms of narcolepsy are present. But if the sleep attacks are isolated and cataplexy is mild or absent, diagnosis is more difficult. It is also possible for cataplexy to occur in isolation.
Formal diagnosis may require staying overnight at a sleep center where you undergo an in-depth analysis of your sleep by a team of specialists. Methods of diagnosing narcolepsy and determining its severity include:
- Sleep History: Your health care provider will want to obtain from you a detailed history so that the onset of your illness, and any other factors that could help explain your symptoms, are fully considered. A part of the history involves filling out the Epworth Sleepiness Scale, which uses a series of short questions to gauge your degree of sleepiness. You will rank on a numbered scale how likely it is that you would doze off in certain situations, such as sitting down after lunch.
Questionnaires may be used in the assessment of patients with symptoms that suggest narcolepsy. The Stanford Narcolepsy Questionnaire is an extensive questionnaire that can provide the health care provider with valuable information on all symptoms of narcolepsy, but especially on cataplexy. The Epworth Sleepiness Scale is a brief self-administered questionnaire that provides an estimate of the degree of daytime sleepiness. A person rates the likelihood of falling asleep during specific activities. Using the scale from 0-3 below, the person ranks their risk of dozing in the chart below.
SITUATION RISK OF DOZING Sitting and reading. Watching television. Sitting inactive in a public place. As a passenger in a car riding for an hour, no breaks. Lying down to rest in the afternoon. Sitting and talking to someone. Sitting quietly after lunch, without action. In a car, while stopped for a few minutes in traffic.
After ranking each category, the total score is calculated. The range is 0-24, with the higher score the more sleepiness.
- 0-9 = Average daytime sleepiness.
- 10-15 = Excessive daytime sleepiness.
- 16-24 = Moderate to severe daytime sleepiness.
- Actigraphy: You may be asked to keep a detailed diary of your sleep pattern for a week or two or even 3 weeks, so that your health care provider can compare how your sleep pattern and alertness are related. Sleep diaries record the patient's usual sleep patterns (sleep deprivation, irregular sleep/wake pattern, interrupted sleep), alcohol and/or drug use, and common behaviors that causes the patient to lose sleep (such as Internet syndrome - surfing the Internet until late at night, causing sleep deprivation and daytime sleepiness). Often, in addition to this "sleep log," the health care provider will ask you to wear an actigraph. This device has the look and feel of a wrist watch and measures how and when you sleep.
Two tests that are commonly used in diagnosing narcolepsy are the polysomnogram and the multiple sleep latency test (MSLT). These tests are usually performed by a sleep specialist in a sleep laboratory.
- Polysomnogram: This test measures a variety of signals during sleep using electrodes placed on your scalp before you fall asleep. For this test, you must stay overnight for observation at a medical facility. The test measures the electrical activity of your brain (electroencephalogram) and heart (electrocardiogram), the movement of your muscles (electromyogram) and eyes (electro-oculogram), and monitors your breathing. The polysomnogram involves continuous recording of sleep brain waves and a number of nerve and muscle functions during nighttime sleep. When tested, people with narcolepsy fall asleep rapidly, enter REM sleep early, and may awaken often during the night. The polysomnogram also helps to detect other possible sleep disorders that could cause daytime sleepiness.
- Multiple Sleep Latency Test: This examination measures how long it takes for you to fall asleep during the day. You will be asked to fall asleep for a series of four or five naps during normal wake times, each nap two hours apart. Specialists will observe your sleep patterns. Observations are made of the time taken to reach various stages of sleep (sleep onset latency). People who have narcolepsy fall asleep easily and enter into rapid eye movement (REM) sleep quickly. This test measures the degree of daytime sleepiness and also detects how soon REM sleep begins.
Daytime sleepiness is measured in the MSLT by the sleep latency (SL) time. This is the time from the beginning of the recording to the onset of sleep. In healthy individuals, the SL time is more than 10 minutes, whereas in narcolepsy, it could be as short as 0.5 minutes (an almost immediate onset of sleep).
These tests provide objective measures of daytime sleepiness and REM sleep abnormalities. They can also help health care providers and researchers rule out other possible causes of your signs and symptoms. Other sleep disorders, such as sleep apnea, can cause excessive daytime sleepiness.
OTHER TESTS
REM Sleep Evaluation: REM sleep is named for the rapid eye movements (REM) that characterize this phase of sleep. In REM sleep dreams are vivid, muscle activity is suppressed, and brain activity is high. The REM sleep abnormality that is characteristic of narcolepsy is referred to as sleep onset REM periods. In healthy individuals, the first REM sleep period occurs about 80 to 120 minutes after the onset of sleep. By contrast, in narcolepsy, the initial REM sleep period usually occurs within 15 minutes of the onset of sleep. In addition, narcolepsy patients will have two or more sleep onset REM periods during the multiple sleep latency test (MSLT) in the daytime.
PSG is also helpful in excluding other causes of daytime sleepiness, such as sleep apnea syndrome (SAS), periodic limb movements in sleep (PLMS), and sleep disruptions. In some cases, repeat tests may be recommended if there is worsening of the symptoms of narcolepsy despite treatment or if an additional sleep disorder is suspected (for example, sleep apnea syndrome).
Maintenance of Wakefulness Test (MWT): Maintenance of wakefulness test (MWT) may be used to evaluate the effects of the treatment for narcolepsy. This test is a recording that measures the ability of a subject to stay awake during the day.
The diagnostic criteria for narcolepsy are described in the International Classification of Sleep Disorders. These criteria indicate that the diagnosis may be based on clinical symptoms alone if both excessive daytime sleepiness and cataplexy are present. If cataplexy is not present, however, the diagnosis should be based on the clinical symptoms and polysomnographic findings.
The Blood Test For A Type of HLA: The blood test for a type of HLA (Human Leukocyte Antigen) has been observed to have a very high association with narcolepsy. Certain types of HLA are part of an individual's genetic or hereditary makeup and can be characteristic of certain conditions, especially autoimmune diseases. The particular HLA type associated with narcolepsy is not unique for this condition as it is also found in 20 percent of the general population. Therefore, HLA typing should not be used for the diagnosis of narcolepsy.
CONVENTIONAL MEDICAL TREATMENT
There is no cure for narcolepsy, but medications and lifestyle modifications can help you to manage the symptoms. Treatment is tailored to the individual based on symptoms and therapeutic response. The types, number, and severity of the symptoms determine which drugs are used to treat the narcolepsy. Severe daytime sleepiness may require treatment with high doses of stimulant medication, and sometimes a combination of stimulants may be needed. Rare or infrequent cataplexy and other associated symptoms may not require any drug treatment, or treatment on an "as needed" regimen may be adequate. Insomnia and depression may also require treatment.
Therapy should be catered to the individual needs of the patient. For example, improved alertness may be critical throughout the day for most students and working adults, but may be critical only at certain times of the day (for example, driving times) for other people. Alerting medications are used for the treatment of excessive daytime sleepiness.
The time required to achieve optimal control of symptoms is highly variable, and may take several months or longer. Medication adjustments are also frequently necessary, and complete control of symptoms is seldom possible. While oral medications are the mainstay of formal narcolepsy treatment, lifestyle changes are also important. The main treatment of excessive daytime sleepiness in narcolepsy is with a group of drugs called central nervous system stimulants. For cataplexy and other REM-sleep symptoms, antidepressant medications and other drugs that suppress REM sleep are prescribed.
STIMULANTS
Stimulants are drugs that stimulate the central nervous system and are the primary treatment to help people with narcolepsy stay awake during the day. The drowsiness is normally treated using amphetamine-like stimulants such as methylphenidate (Ritalin), racemic amphetamine, dextroamphetamine (Dextrostat, Dexedrine), and methamphetamine hydrochloride (Desoxyn), or amphetamine and dextroamphetamine (Adderall). However, they can also produce undesirable side effects including elevation of blood pressure, nervousness, irritability, and rarely, paranoid reactions. Alerting medications can also lead to drug dependency due to the feeling of euphoria they can cause. However, drug dependency has rarely been described in individuals with narcolepsy.
Pemoline (Cylert) is used as an alerting medication but it is less effective than traditional stimulants. This drug has the potential risk of toxic side effects on the liver and liver blood tests need to be monitored frequently.
Modafinil (Provigil) is a newer stimulant with a different pharmacologic mechanism. In 1999, after successful clinical trial results, the FDA approved the drug called modafinil for the treatment of EDS. Modafinil has alerting effects similar to those of the traditional stimulant. Modafinil is not a general CNS stimulant like amphetamines, but the precise way it works is unknown. It is not supposed to be as addictive and does not produce the highs and lows often associated with older stimulants.
Modafinil has a much lower risk for high blood pressure and mental side effects because it acts in a different way than classic stimulants. It does not have significant effects on the sympathetic nervous system and does not cause mood changes, euphoria, or dependence. Furthermore, modafinil does not become ineffective with prolonged use. Headache and nausea are the most commonly reported side effects, and they are usually mild and temporary. These side effects can be reduced by a slow increase from a low initial dose up to the desired dose. This medication does not affect cataplexy and other REM sleep symptoms.
Modafinil is usually used in a single daily dose. Switching patients from amphetamines to modafinil may cause the reappearance of cataplexy in patients previously well controlled. Increasing the dose or adding an anti-cataplectic medication usually solves this problem.
In the Fall of 2007 an alert for severe adverse reactions to modafinil was issued by the FDA. Some people need treatment with methylphenidate or the other various amphetamines. Although these medications are effective, they may cause side effects, such as nervousness and heart palpatations, and can be addictive.
ANTIDEPRESSANTS
Health care providers often prescribe antidepressant medications, which suppress REM sleep, to help alleviate the symptoms of cataplexy, hypnagogic hallucinations and sleep paralysis. Anticataplectic medication is the general name for drugs that are used to treat cataplexy. Two classes of antidepressant drugs have proved effective in controlling cataplexy in many patients: tricyclics, including imipramine (Tofranil), desipramine, clomipramine, and protriptyline (Vivactil) and selective serotonin reuptake inhibitors (SSRIs) including fluoxetine (Prozac, Sarafem) and sertraline (Zoloft).
Tricyclic Antidepressants (TCAs): TCAs are used in lower than antidepressant doses, are often effective in controlling cataplexy. These medications act on neurotransmitter systems to produce suppression of REM sleep and consequently improve the symptoms of cataplexy.
In some cases, the side effects may limit the use of TCAs, although in most cases the side effects are temporary. The most frequent side effects are called "anticholinergic side effects," including dry mouth, dry eyes, blurred vision, urine retention, constipation, impotence, increased appetite, drowsiness, nervousness, confusion, restlessness, and headache. Some of the TCAs may increase periodic limb movements in sleep, which could further disrupt already disturbed nighttime sleep in narcoleptic patients. If TCAs are abruptly discontinued, a significant worsening of the cataplexy and other REM related symptoms could occur. This "rebound phenomenon" may appear in 72 hours after discontinuation of the medication and peak in approximately 10 days from the withdrawal.
The most frequently used TCAs for the treatment of cataplexy and other REM related symptoms are protriptyline (Vivactil), imipramine (Tofranil), clomipramine (Anafranil), desipramine (Norpramine), and amitriptyline (Elavil). Sedating TCAs such as clomipramine, amitriptyline, and imipramine, are usually prescribed for evening use, whereas the alerting ones (protriptyline and desipramine) are recommended for use during the day.
Selective Serotonin Reuptake Inhibitors (SSRIs): SSRIs are also useful in treating cataplexy at doses that are comparable to those used to treat depression. The most frequently used SSRIs for treatment of cataplexy and REM related symptoms are fluoxetine (Prozac), paroxetine (Paxil), sertraline (Zoloft), citalopram (Celexa), and venlafaxine (Effexor). The SSRIs may not be as effective as the TCAs, but they have fewer side effects. The most frequently reported side effects are dizziness, lightheadedness, nausea, and mild tremor. Rarely, mild constipation or diarrhea may occur. Fluoxetine (Prozac) given late in the day may cause insomnia.
Monoamine oxidase inhibitors (MAOIs): A class of antidepressants called monoamine oxidase inhibitors (MAOIs) can also be used for treatment of excessive daytime sleepiness. This includes phenelzine (Nardil) and selegiline (Eldepryl).
Drug therapy should be supplemented by behavioral strategies. For example, many people with narcolepsy take short, regularly scheduled naps at times when they tend to feel sleepiest. Improving the quality of nighttime sleep can combat EDS and help relieve persistent feelings of fatigue. Among the most important common-sense measures people with narcolepsy can take to enhance sleep quality are actions such as maintaining a regular sleep schedule, and avoiding alcohol and caffeine-containing beverages before bedtime.
SODIUM OXYBATE (XYREM)
On July 17, 2002, the FDA approved Xyrem (sodium oxybate or gamma hydroxybutyrate, also known as GHB) for treating people with narcolepsy who experience episodes of cataplexy, and in 2005 was also approved to treat excessive daytime sleepiness (EDS). Gamma-hydroxybutyrate (GHB), a medication recently approved by the US Food and Drug Administration, is the only medication specifically indicated for cataplexy. GHB has also been shown to reduce symptoms of EDS associated with narcolepsy. GHB is usually administered in two doses; the first is given at bedtime and the second four hours later. While the exact mechanism of action is unknown, GHB is thought to unify sleep and improve the quality of disturbed nocturnal (nighttime) sleep characteristic of narcolepsy. Sodium oxybate / GHB helps to improve nighttime sleep, which is often poor in narcolepsy. This nighttime benefit may help decrease daytime drowsiness and cataplexy. Sodium oxybate is unrelated to drugs that are known to be sleep-inducing (hypnotic) and is not used for insomnia. In high doses it may also help control daytime sleepiness, even though you take it only at night. It can cause drowsiness and should only be taken at night. However, because the use of this drug has been associated with serious side effects, such as trouble breathing during sleep, sleepwalking and bed-wetting and due to safety concerns associated with the use of this drug, the distribution of Xyrem is strictly restricted and regulated by the Food and Drug Administration.
OTHER MEDICATIONS
Other medications used are codeine and selegiline. Another drug that is used is atomoxetine (Strattera), a non-stimulant and Norepinephrine reuptake inhibitor (NRI), that has little or no abuse potential.
ADDITIONAL TREATMENT THERAPY
If you have other health problems, such as high blood pressure or diabetes, ask your health care provider how medications for existing conditions may interact with those taken for narcolepsy. Certain over-the-counter drugs, such as allergy and cold medications, can cause drowsiness as a side effect. If you have narcolepsy, your health care provider will likely recommend that you avoid taking these medications.
Medications to treat narcolepsy can help reduce your signs and symptoms, but they cannot alleviate them entirely. Lifestyle changes (see below) also are an integral part of treating narcolepsy.
Ongoing communication between the health care provider, patient, and the patient's family members is important for optimal management of narcolepsy.
Finally, a recent study reported that transplantation of hypocretin neurons into the pontine reticular formation in rats is feasible, indicating the development of alternative therapeutic strategies in addition to pharmacological interventions.
NON-DRUG & LIFESTYLE MODIFICATIONS
Non-drug treatments include education of the patient and family members and modification of behavior patterns. Understanding the symptoms of narcolepsy may help relieve some of the frustrations, fears, anger, depression, and resentment of patients and family members. Emotional reactions are responses to both the unusual nature of the symptoms and society's ignorance of this disease. National organizations and local narcolepsy support groups are additional sources of information and assistance. Lifestyle modifications are important in managing the symptoms of narcolepsy. You may benefit from these steps:
- Behavioral approaches include establishing a regular, structured sleep-wake schedule. Stick to a schedule. Go to sleep and wake up at the same time every day, including weekends.
- In addition to drug therapy, an important part of treatment is scheduling short naps at regular intervals during the day. Take several short daily naps of 10-30 minutes or longer two to three times per day at strategic times during the day may be refreshing and used to combat and reduce excessive sleepiness and sleep attacks for one to three hours. These are used to help control excessive daytime sleepiness and help the person stay as alert as possible. Daytime naps are not a replacement for nighttime sleep.
- Certain dietary restrictions should be observed (for example, avoidance of large meals and alcohol). Avoid nicotine and alcohol. Using these substances, especially at night, can worsen your signs and symptoms.
- Get regular exercise. Regular exercise and exposure to bright light can improve alertness. Take several short walks during the day. Moderate, regular exercise at least four to five hours before bedtime may help you feel more awake during the day and sleep better at night.
- Break up larger tasks into small pieces and focusing on one small thing at a time. Special considerations may be needed for school schedules and working conditions. Occupations that require working in shifts, changing the work schedule, or driving should be avoided. The dangers of driving while sleepy and/or experiencing cataplexy need to be addressed and the patients should be advised to avoid driving with these symptoms. However, many patients with narcolepsy are able to drive for short distances at certain times of the day and after taking their stimulant medications. Reporting requirements to the Department of Motor Vehicles (DMV) differ from state to state. Some states require that individuals who have any lapses of consciousness or sleepiness be reported to the DMV.
- Occupational, marriage, and family counseling may help improve the patient's quality of life.
PROGNOSIS
Narcolepsy is a life-long disease. The symptoms may vary in severity during the patient's lifespan, but they never disappear completely. Symptoms usually gradually worsen over time, and then tend to become stable. Even then, the excessive daytime sleepiness may become more pronounced and require additional medication. At other times, cataplexy or the other symptoms may decrease or even disappear for a time.
None of the currently available medications enables people with narcolepsy to consistently maintain a fully normal state of alertness. But EDS and cataplexy, the most disabling symptoms of the disorder, can be controlled in most patients with drug treatment. Often the treatment regimen is modified as symptoms change. Whatever the age of onset, patients find that the symptoms tend to get worse over the two to three decades after the first symptoms appear. Many older patients find that some daytime symptoms decrease in severity after age 60.
Different factors contribute to changes in a patient's symptoms, including an irregular sleep/wake schedule, the use of substances or drugs that affect the central nervous system, infections of the brain, and the development of additional sleep disorders, such as sleep apnea syndrome (SAS), periodic limb movements in sleep syndrome (PLMS), or others. Regular health care provider check-ups and adherence to the drug plan and behavioral treatment may diminish these fluctuations and improve the patient's symptoms and quality of life.
A primary care health care provider, usually in collaboration with a sleep medicine specialist, can recognize the symptoms of narcolepsy, initiate the proper evaluation, and manage the treatment that is recommended by the specialist.
NARCOLEPSY RESEARCH
The discovery that a lack of hypocretins in the cerebrospinal fluid (CSF) may be related to the cause of narcolepsy could lead to the development of tests to determine the level of hypocretins in the CSF. Such tests could help in the diagnosis of narcolepsy. The expectation is that these tests will be simple (drawing blood), and will reflect the level of hypocretins in the CSF. In addition, the discovery of the role of hypocretins in the development of narcolepsy may lead to the development of new drugs for the treatment of narcolepsy.
The National Institute of Neurological Disorders and Stroke (NINDS) and other institutes of the National Institutes of Health (NIH) conduct research into narcolepsy and other sleep disorders in laboratories at the NIH and also support additional research through grants to major medical institutions across the country. The NINDS continues to support investigations into the basic biology of sleep, including the brain mechanisms involved in generating and regulating sleep. Within the National Heart, Lung, and Blood Institute, also a component of the NIH, the National Center on Sleep Disorders Research (NCSDR) coordinates Federal government sleep research activities and shares information with private and non-profit groups.
COPING WITH NARCOLEPSY
Learning as much about narcolepsy as possible and finding a support system can help patients and families deal with the practical and emotional effects of the disorder, possible occupational limitations, and situations that might cause injury. A variety of educational and other materials are available from sleep medicine or narcolepsy organizations.
Join a support group. Support groups exist to help persons with narcolepsy and their families. Support groups and counseling can help you and your loved ones cope with narcolepsy. Ask your health care provider to help you locate a group or qualified counselor in your area.
To imagine what a person with narcolepsy copes with daily, keep in mind that while many are not sleep-deprived (in the classical sense), a major symptom of narcolepsy is akin to sleep deprivation in a normal person; as a normal person, imagine going years functioning off just 3-4 hours of sleep per night. While lifestyle changes and drug therapy can help largely mitigate many symptoms of narcolepsy, there currently exists no complete and permanent solution, therefore patience, empathy and self-education are excellent coping tools.
Individuals with narcolepsy, their families, friends, and potential employers should know that:
- Narcolepsy is a life-long condition that may require continuous medication.
- Although there is no cure for narcolepsy at present, several medications can help reduce its symptoms.
- People with narcolepsy can lead productive lives with proper medical care and lifestyle changes.
- A major physiological and physical effect of narcolepsy is roughly akin to the effects of sleep deprivation; such effects can often be controlled and minimized through a combination of lifestyle changes and drug therapy.
- Do not drive or operate dangerous equipment if you are sleepy. Take a nap before driving if possible. If you must drive a long distance, work with your health care provider to establish a medication schedule that ensures the greatest likelihood of wakefulness during your drive. Consider stopping and taking a break for a nap and exercise breaks whenever you feel drowsy during a long driving trip. Do not drive if you feel your sleepiness is not well controlled. Individuals with narcolepsy should avoid jobs that require driving long distances or handling hazardous equipment or that require alertness for lengthy periods (especially where the consequences of falling asleep are dangerous to themselves or others).
- Parents, teachers, spouses, co-workers, friends and employers should be aware of the symptoms of narcolepsy. Talk about it. This will help them avoid the mistake of confusing the person's behavior with laziness, hostility, rejection, or lack of interest and motivation. It will also help them provide essential support and cooperation.
- Tell your employer or teachers about your condition and work together to find ways to accommodate your needs at work or school. Employers can promote better working opportunities for individuals with narcolepsy by permitting special work schedules and nap breaks. Carry a tape recorder, if possible, to record important conversations and meetings. This may include not only taking nap breaks during the day but also breaking up monotonous tasks, recording meetings or classes, standing during meetings or lectures, and taking brisk walks at various times throughout the day. The Americans With Disabilities Act prohibits discrimination against workers with narcolepsy and requires employers to provide reasonable accommodation to qualified employees.
ORGANIZATIONS
Narcolepsy Network, Inc.
79 Main Street
North Kingstown, RI 02852
E-mail: narnet@narcolepsynetwork.org
Website: www.narcolepsynetwork.org
Tel: 888-292-6522, 401-667-2523
Fax: 401-633-6567
National Sleep Foundation
1522 K Street NW
Suite 500
Washington, DC 20005
E-mail: nsf@sleepfoundation.org
Website: www.sleepfoundation.org
Tel: 202-347-3472
Fax: 202-347-3472
National Heart, Lung, and Blood Institute (NHBLI)
National Institutes of Health, DHHS
31 Center Drive, Rm. 4A21 MSC 2480
Bethesda, MD 20892-2480
Website: www.nhlbi.nih.gov
Tel: 301-592-8573
TTY: 240-629-3255
Recorded Info: 800-575-WELL (-9355)
CONSIDERATIONS
Narcolepsy and sleep apnea are the leading causes of tiredness during the day.
A diagnosis of narcolepsy may involve a multiple sleep latency test (MSLT), usually conducted in a sleep disorders clinic. You may be referred on to "sleep specialists" for diagnosis.
Irregular sleep patterns are just as likely to cause drowsiness as lack of sleep. Jet lag, shift work, inconsistent bedtimes, and weekend partying can all disturb our natural sleep/wake cycles. Use of alcohol and recreational drugs and some medications can also alter and disrupt normal sleep patterns. America is a nation of sleep-starved yawners fighting a daily battle against the sandman. We live in a world where people drive themselves on relentless schedules that leave insufficient time for quality sleep.
There have been documented cases in which persons who suffered from narcolepsy were cured by eliminating allergic foods from the diet. One person, for instance, was found to have an allergy to potatoes. When he removed potatoes from his diet, he no longer experienced the symptoms. If you know or suspect allergies and have symptoms of narcolepsy, schedule an appointment with an allergist for consultation and possible testing. If you can find a cause and treatment without having to use drug therapy and simply by altering your diet and lifestyle habits, this is a preferred choice.
MoonDragon's Health & Wellness: Allergies
There is some evidence that the immune systems of people who suffer from narcolepsy may react abnormally to the chemical processes in the brain cause sleep.
Certain dogs, mainly Doberman pinschers, have been observed to sleep excessively and to collapse when overstimulated. Research has revealed a withering away of axons (the "communication cables" that convey signals between nerve cells) in the brains of these animals, especially in 3 regions of the brain that have been linked to sleep inhibition, motor control, and the processing of emotions. If similar degeneration can be demonstrated in human brains, this may offer further clues as to the causes of narcolepsy.
Health care providers traditionally prescribed stimulants (amphetamines) and antidepressants for people with narcolepsy. A newer drug, modafinil (Provigil), acts on the hypothalamus, a part of the brain responsible for wakefulness, and may reduce sleep attacks. This drug should not be used by people with heart conditions, liver dysfunction, or a history of mental illness, and it can reduce the effectiveness of certain birth control methods.
Sleep apnea is a potentially serious disorder that can cause repeated waking throughout the night. This problem is commonly associated with snoring and extremely irregular breathing throughout the night. In sleep apnea, breathing actually stops, for as long as two minutes at a time, while the individual is asleep. When breathing stops, the level of oxygen in the blood drops, resulting in oxygen deprivation. The individual then awakens, startled and gasping. A person with sleep apnea may awaken as many as 200 times throughout the night. The affected individual may not remember these awakenings, but anyone else who is awake at the time can naturally become alarmed when a person with sleep apnea stops breathing.
Aside from disrupting normal sleep and causing extreme sleepiness during the day, sleep apnea is associated with other, more serious, health problems. People who suffer from sleep apnea tend to have higher than normal blood pressure and are more likely to have strokes than the general population, and face an increased risk of heart disease, although the reason or reasons for these links are not known. People with sleep apnea also seem to have a higher than normal incidence of emotional and psychotic disorders. Experts attribute this to what they call a "dream deficit" -- a lack of adequate rapid eye movement (REM) sleep, the stage of sleep in which dreaming occurs. A person with sleep apnea often cannot settle into REM sleep for even the eight to twelve seconds it takes to have a normal, healthy dream. While there is much about the phenomenon of dreaming that is not understood, it is known that prolonged periods of REM sleep deprivation can induce various psychoses and other serious emotional disorders.
DIETARY, HERBAL & HOLISTIC RECOMMENDATIONS
HERBS
Gotu Kola and St. John's Wort boost energy levels and possess antioxidant properties as well.
Herbal Remedies: Gotu Kola Information
Herbal Remedies: Gotu Kola Supplements & Products
Herbal Remedies: St. John's Wort Information
Herbal Remedies: St. John's Wort Supplements & Products
Ginkgo Biloba, improves circulation to the brain and is a powerful antioxidant for protecting cells.
Herbal Remedies: Ginkgo Biloba Information
Herbal Remedies: Ginkgo Biloba Supplements & Products
RECOMMENDATIONS
Eat a low-fat diet high in cleansing foods such as leafy green vegetables and sea vegetables. Also eat foods high in the B-Vitamins, such as brewer's yeast and brown rice.
Eat foods high in protein (meats, poultry, cheese, nuts, seeds, and soy products) in the middle of the day, and save the complex carbohydrates (fresh fruit and vegetables, legumes, natural whole grains, and pasta) for the evening meal. High protein foods increase alertness, whereas carbohydrates have a calming effect and can promote sleepiness.
Include in the diet foods rich in the amino acid tyrosine. Good choices include eggs, oats, poultry, and wheat germ. Caution: If you are taking a MAO inhibitor drug, Avoid foods containing tyrosine, as drug and dietary interactions can cause a sudden, dangerous rise in blood pressure. Discuss food and medicine limitations thoroughly with your health care provider or a qualified dietician.
Avoid alcohol and sugar. They may seem stimulating initially, but will only make you tired later.
Check for food allergies. If you suspect a mild food allergy, consider using an elimination diet to find the food in which you may have sensitivity or an allergy. Consult with an allergist for testing, if necessary of if you have more than a mild allergy.
Exercise daily to improve circulation and oxygenate tissues.
Napping can rejuvenate you when you have lost sleep. Take up to a 45 minute nap in the early afternoon.
Make sure your home and workplace are well lit, either by natural sunlight or overhead lighting. Using full spectrum light bulbs in your home and workplace can help and are best. Light suppresses the production of melatonin, which is the hormone that produces drowsiness.
As much as possible, reduce the anxiety in your life. Stress can be a trigger for increasing tiredness and depression.
NUTRITIONAL SUPPLEMENTS
Unless otherwise specified, the dosages recommended here are for adults. For a child between the ages of 12 and 17 years, reduce the dose to 3/4 the recommended amount. For a child between the ages of 6 and 12, use 1/2 the recommended dose, and for a child under the age of 6, use 1/4 the recommended amount.
NARCOLEPSY SUPPLEMENTS & PRODUCTS
Supplements and products for narcolepsy, a condition that results in overwhelming feelings of sleepiness and fatigue.
Cayenne Pepper Supplement, Nature's Way, 450 mg, 180 Caps
Cayenne Pepper Supplement is a blood warming her that has an invigorating effect on several body systems.Enzyme Phytonutrient (EPN) Ionic Supplement, Fully Absorbable, 16 fl. oz.
WaterOz Ionic EPN is a pure liquid enzyme supplement. EPN complex is a patent-pending enzyme phytonutrient from a plant source that provides enzyme and saccharides necessary for optimal cellular communication. No combination of vitamins, minerals, amino acids or herbals can replace the necessary saccharides found in EPN.Fisol Fish Oil Supplement, EPA DHA, Enteric Coated, Nature's Way, 500 mg, 90 Softgels
Fisol, enteric coated, fish oil supplement delivers 30% EPA and 20% DHA. The unique coating withstands stomach acid so Fisol dissolves in the small intestine and maximizes the body's absorption of Omega-3 Essential Fatty Acids.Ginkgo Biloba Extract, Standardized, Nature's Way, 60 mg, 120 VCaps
Nature's Way Ginkgo biloba extract is a technically and scientifically advanced herbal extract standardized to 24 % Ginkgo flavone glycosides and 6% terpene lactones, supported by whole Gotu Kola herb.Ginkgold, Ginkgo Biloba Extract, Nature's Way, Vegetarian, Standardized, 60 mg, 150 Caps
Backed by over 35 years of extensive research, including over 400 published scientific and clinical studies, Nature's Way Ginkgold ginkgo biloba extract has been proven to support healthy circulation to the brain as well as the extremities.Gotu Kola, Nature's Way, 475 mg, 180 Caps
Gotu Kola (Centella asiatica) is used in India similar to how the Chinese use Ginseng, for longevity and vitality. Although its name is similar to cola nut, Gotu Kola does not contain caffeine.GTF Chromium Polynicotinate, Nature's Way, 200 mcg, 100 Caps
Nature's Way GTF Chromium polynicotinate is the patented ChromeMate polynicotinate form. Chromium polynicotinate meets all the requirements for GTF. It contains no artificial ingredients or preservatives.Lecithin Fine Vegetarian Granules, NOW Foods, 97% Phosphatides, Pure & Fresh, 1 lb.
Contains Choline & Inositol which are essential for the breakdown of fats and cholesterol. It helps prevent arterial congestion, helps distribute bodyweight, increases immunity to virus infections, cleans the liver and purifies the kidneys.L-Glutamine, Amino Acid Supplement, NOW Foods, 1,000 mg, 120 Caps
L-Glutamine is an important amino acid that helps brain function, as it converts quickly into glucose, the only source of energy to the brain. L-Glutamine promotes better thinking ability, and increases the amount of GABA, another amino acid that aids in proper brain function.L-Tyrosine, Pharmaceutical Grade, Free Form, NOW Foods, 500 mg, 120 Caps
L-Tyrosine is used to treat insomnia, improve muscle tone, improve skin and hair pigment and depression and anxiety. L-Tyrosine should not to be used while taking prescription antidepressants or MAO inhibitors.Multiple Effects Oil, TCM Formula Shixiang Baixiangyou, Cold, Headache and Pain Formula, 100% Natural, 0.34 fl. oz.
Multiple-Effects Oil - TCM Cold, Headache and Pain Formula opens stuffy noses, removes headache pain, joint pain and drowsiness.Multi-Vitamin & Mineral For Diabetes, Iron Free, All Natural, Nature's Way, Vegetarian, Completia Diabetic Vitamin Formula, 90 Tabs
Nature's Way Completia Diabetic Vitamin Supplement supports the nutritional needs of individuals with diabetes and the related blood support needed.Nerves Formula Tincture, 2 fl. oz.
The Nerves Formula was created to help calm and soothe the nerves. Can also help arteriosclerosis/atherosclerosis, arthritis, auto-immune diseases.Sleep Formula ZZZZZ Tincture, 100% Organic, 2 fl. oz.
The Sleep Formula ZZZZZ Tincture is used to assist with Nervous Disorders and to help induce and allow for restful sleep.St. John's Wort Tonic (Formerly Depression Tincture), 2 fl. oz.
St. John's Wort Supplement is found to help alleviate depression and strengthen the nervous system.Sublingual Melatonin Supplement, Nature's Way, 2.5 mg, 100 Lozenges
Nature's Way Sublingual Melatonin Supplement is formulated into an advanced sublingual form. Sublingual dosing is the most rapid way to absorb certain nutrients.Vitamin B-6, Pyridoxine, Nature's Way, 100 mg, 100 Caps
Vitamin B6 (pyridoxine) is converted in the body to the main coenzyme responsible for amino acid and protein metabolism.Vitamin B-12 Complex Liquid, NOW Foods, 2 fl. oz.
Vitamin B-12 Helps to maintain a healthy nervous system, and helps in the prevention of pernicious anemia. Folic Acid should be taken by all females of child bearing age to help prevent neuro-tube birth defects. Folic acid is also linked to heart health.Vitamin C 500 With Bioflavonoids, Nature's Way, 100% Natural, 500 mg, 250 Caps
Vitamin C 500 With Bioflavonoids provides antioxidant protection for many of the body's important enzyme systems.Vitamin C 1000 With Bioflavonoids, Nature's Way, 100% Natural, 1000 mg, 250 VCaps
Nature's Way Vitamin C With Bioflavonoids provides antioxidant provides antioxidant protection for many of the body's important enzyme systems.Vitamin C Liquid For Baby & Children, 4 fl. oz.
Vitamin C is known as a principal anti-oxidant, the need for which is greatly increased in infants and children due to today's elevated environmental stresses and pollution.Vitamin E, Natural D-Alpha Tocopherol, 400 IU, 100 Softgels
Vitamin E has potent antioxidant activity, supplies oxygen to the blood, aids in strengthening capillary walls, and plays a beneficial role in cancer and cardiovascular disease prevention, anti-aging benefits, circulation, wound-healing, immune function, nervous system function, PMS, hot flushes, diabetes, vascular disease, eye health, tissue repair, athletic performance, leg cramps, skin and hair health, and alleviating fatigue.Vitamin E, D-Alpha Tocopherol Acetate, 100% Natural, NOW Foods, 400 IU, 250 Softgels
Vitamin E is a major antioxidant and the primary defense against lipid peroxidation. It is particularly important in protecting the body's cells from free radical/oxidative damage.
Herbal Remedies: Narcolepsy Information
Herbal Remedies: Narcolepsy Supplements, Information & Products
NOTIFY YOUR HEALTH CARE PROVIDER IF...
See your health care provider if you experience excessive daytime sleepiness that seriously disrupts your personal or professional life.
If you experience unusual or unexpected side effects from medications used for treatment.
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The Complete Guide to Natural Healing
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