From the Guidelines
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be considered the first-line treatment for adults with sleep onset insomnia, as it has been shown to improve global outcomes, reduce sleep onset latency, and improve sleep quality 1.
Treatment Options
Treatment options for sleep onset insomnia include both non-pharmacological and pharmacological approaches.
- Non-pharmacological approaches include CBT-I, which involves sleep restriction, stimulus control, relaxation techniques, and sleep hygiene education.
- Patients should maintain consistent sleep-wake times, avoid screens before bed, create a comfortable sleep environment, and limit caffeine and alcohol.
Pharmacological Options
For short-term medication options, prescription medications include:
- Short-acting benzodiazepines like triazolam (0.125-0.25mg) 1
- Non-benzodiazepine hypnotics like zolpidem (5-10mg), eszopiclone (1-3mg), and zaleplon (5-20mg) 1
- Orexin receptor antagonists like suvorexant (10-20mg) 1 These medications should generally be used for 2-4 weeks maximum to prevent dependence.
Important Considerations
- The American College of Physicians recommends that clinicians use a shared decision-making approach, including a discussion of the benefits, harms, and costs of short-term use of medications, to decide whether to add pharmacological therapy in adults with chronic insomnia disorder in whom CBT-I alone was unsuccessful 1.
- The American Academy of Sleep Medicine suggests that clinicians use suvorexant, eszopiclone, zaleplon, and zolpidem as treatments for sleep onset insomnia in adults 1.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation.
The treatment options for sleep onset insomnia include:
- Ramelteon (PO): indicated for the treatment of insomnia characterized by difficulty with sleep onset 2, 2
- Zolpidem (PO): indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation 3
From the Research
Treatment Options for Sleep Onset Insomnia
The treatment options for sleep onset insomnia include:
- Nonpharmacologic options such as stimulus control, sleep hygiene education, sleep restriction, paradoxical intention, relaxation therapy, biofeedback, and cognitive behavioral therapy 4
- Prescription and over-the-counter drug therapies including benzodiazepine and nonbenzodiazepine sedative-hypnotic agents, ramelteon, a melatonin receptor agonist, trazodone, and sedating antihistamines 4
- Herbal and alternative preparations such as melatonin and valerian 4
- Cognitive-behavioral therapy for insomnia (CBT-I) which is the mainstay of treatment and is a safe and effective approach 5
- Newer generation nonbenzodiazepines (eg, zolpidem, zaleplon) which are used as first-line pharmacotherapy for chronic insomnia 5
- Melatonin agonists such as ramelteon which can be effective for improving sleep quality without the adverse effects associated with hypnotic-sedatives 6
Considerations for Treatment
When selecting a treatment for sleep onset insomnia, clinicians should consider patient-specific criteria such as:
- Age 4, 7
- Medical history 4, 7
- Other drug use 4, 7
- Underlying cause of the sleep disturbance 4
- Efficacy for the patient's specific complaint as well as other features such as safety profile and abuse liability 7
Special Considerations for Older Adults
Older adults with insomnia disorder require careful consideration of medications' risk-benefit profiles 7