From the Guidelines
For patients experiencing headaches and fatigue while taking trazodone for sleep, the most appropriate alternative treatment is to switch to eszopiclone (1-3mg) or zolpidem (5-10mg) at bedtime, as these medications have been shown to improve sleep efficiency and reduce sleep onset latency with a more favorable benefit-to-risk ratio compared to trazodone 1.
Non-Medication Approaches
Before considering medication, non-medication approaches should be tried first, including:
- Consistent sleep schedules
- Avoiding screens before bedtime
- Creating a comfortable sleep environment
- Practicing relaxation techniques like deep breathing or meditation
Medication Options
If medication is needed, other possibilities include:
- Melatonin (starting at 1-3mg taken 1-2 hours before bedtime), which works by supplementing the body's natural sleep hormone
- Diphenhydramine (25-50mg at bedtime), which causes drowsiness through antihistamine effects
- Ramelteon (8mg) at bedtime
- Low-dose mirtazapine (7.5-15mg) can help with sleep while potentially treating underlying depression with fewer headache side effects
Cognitive Behavioral Therapy for Insomnia (CBT-I)
CBT-I is highly effective and provides long-term benefits without medication side effects. When switching from trazodone, it's essential to taper off gradually under medical supervision to avoid withdrawal symptoms, and to address any underlying conditions like depression or anxiety that may be affecting sleep 1.
Trazodone Discontinuation
The work group advised against the use of trazodone for treatment of chronic insomnia disorder due to its adverse effect profile and lack of efficacy in improving sleep efficiency or reducing sleep onset latency compared to placebo 1.
Key Considerations
When selecting an alternative treatment, it's crucial to consider the patient's response to the first medication, and to choose a medication with a suitable pharmacokinetic profile, such as a longer-acting or shorter-acting medication, depending on the patient's specific needs 1.
From the FDA Drug Label
Trazodone Hydrochloride Tablets can cause serious side effects or death, including: ... The most common side effects of Trazodone Hydrochloride Tablets include: swelling blurred vision dizziness sleepiness tiredness diarrhea stuffy nose weight loss Low sodium in your blood (hyponatremia). Symptoms of hyponatremia include: headache, feeling weak, feeling confused, trouble concentrating, memory problems and feeling unsteady when you walk.
The patient is experiencing headaches and fatigue while taking trazodone for sleep. Considering the side effects of trazodone, it is possible that the headaches and fatigue are related to the medication. Alternative treatments for sleep that may be considered include:
- Other antidepressants with a different side effect profile
- Non-benzodiazepine sedatives
- Melatonin receptor agonists However, any changes to the patient's medication regimen should be made under the guidance of a healthcare provider 2.
From the Research
Alternative Treatments for Insomnia
When a patient experiences headaches and fatigue while taking trazodone for sleep, alternative treatments can be considered.
- Nonpharmacologic options include stimulus control, sleep hygiene education, sleep restriction, paradoxical intention, relaxation therapy, biofeedback, and cognitive behavioral therapy 3.
- Prescription and over-the-counter drug therapies include benzodiazepine and nonbenzodiazepine sedative-hypnotic agents, ramelteon, a melatonin receptor agonist, and sedating antihistamines 3.
- Herbal and alternative preparations include melatonin and valerian 3.
Pharmacologic Options
Pharmacologic options for insomnia include:
- Ramelteon, which has a minimal adverse effect profile and is effective for sleep-onset latency and increased total sleep time 4.
- Suvorexant, which improves sleep maintenance and has mild adverse effects, including somnolence 4.
- Low-dose antidepressants, such as trazodone, which should only be used for insomnia when the patient has comorbid depression 4, 5.
Considerations for Treatment
When considering alternative treatments, clinicians should take into account patient-specific criteria such as age, medical history, and other drug use, as well as the underlying cause of the sleep disturbance 3, 4.