A hiatal hernia occurs when the upper part of the stomach pushes upward through the hiatus, the small opening in the diaphragm muscle. This displacement can disrupt the function of the lower esophageal sphincter (LES), the muscular ring that keeps stomach contents contained. When the LES is compromised, stomach acid and digestive juices flow back into the esophagus, causing acid reflux or gastroesophageal reflux disease (GERD). This backward flow is particularly problematic at night because the horizontal sleeping position eliminates the assistance of gravity. Lying flat allows acidic contents to pool against the esophageal lining, resulting in severe nocturnal heartburn and sleep disruption.
Optimizing Sleeping Position
The most effective physical adjustment for managing nocturnal reflux is using gravity to keep the esophagus above the stomach. This requires elevating the head of the bed by at least six to eight inches, a height proven to help prevent acid reflux when lying down. Simply stacking pillows under your head is insufficient because it only flexes the neck and waist, which can increase abdominal pressure and worsen reflux. Instead, elevation should be achieved by placing blocks or specialized risers beneath the bed frame’s legs, or by utilizing a foam wedge that props up the entire torso.
A supportive wedge pillow or bed risers ensure your whole upper body is on an incline. This position helps stomach contents drain back down, minimizing the time acid contacts the esophageal lining. Sleeping on the left side is also recommended, as the stomach sits below the esophagus in this position, further discouraging acid backflow. Avoid sleeping flat on your back or stomach, as these positions apply pressure to the abdomen and make reflux easier. Maintaining this consistent angle while you sleep can dramatically reduce the frequency and intensity of nighttime symptoms.
Managing Evening Intake
Adjusting the timing and content of evening meals is a powerful strategy to reduce nighttime reflux symptoms. The “3-hour rule” suggests avoiding any food or large liquid intake within three hours of lying down for sleep. This waiting period allows the stomach sufficient time to empty its contents into the small intestine before you assume a horizontal position. Lying down with a full stomach greatly increases the volume and pressure available to reflux into the esophagus.
Certain foods and beverages are known to trigger reflux by relaxing the lower esophageal sphincter. Common nighttime offenders include caffeine, alcohol, chocolate, and mint, all of which can weaken LES pressure. Fatty or fried foods should also be avoided in the evening because they take longer to digest. Highly acidic items, such as citrus fruits and tomato-based sauces, can also irritate the sensitive esophageal lining.
Addressing Persistent Symptoms
If lifestyle and positional adjustments do not adequately control nocturnal symptoms, over-the-counter (OTC) medications can provide short-term relief. Antacids work quickly by neutralizing stomach acid, offering fast but temporary comfort for occasional flare-ups. For more persistent symptoms, acid-reducing medications like H2 blockers (e.g., famotidine) or proton pump inhibitors (PPIs, e.g., omeprazole) are available without a prescription. H2 blockers reduce the amount of acid the stomach produces, while PPIs block acid production more completely, allowing the esophagus time to heal.
It is important to discuss the use of these OTC acid reducers with a healthcare provider before using them long-term or frequently. Chronic or high-dose use of certain medications may carry risks and should be medically supervised.
When to See a Doctor
Persistent, severe nocturnal symptoms or new concerning issues warrant immediate consultation with a doctor. These issues include difficulty swallowing, unexplained weight loss, or vomiting. A medical professional can confirm the diagnosis, rule out other conditions, and determine if prescription-strength treatment or further testing, like an endoscopy, is necessary.