Medications for Sleeping Problems
For adults with chronic insomnia, use eszopiclone (2-3 mg), zolpidem (10 mg), or suvorexant (10-20 mg) as first-line pharmacologic options when cognitive behavioral therapy is unavailable or insufficient. These agents have the strongest evidence for improving both sleep onset and maintenance with acceptable safety profiles 1.
Treatment Algorithm
Step 1: Determine Insomnia Type
- Sleep onset insomnia (difficulty falling asleep): Consider zaleplon (10 mg), triazolam (0.25 mg), ramelteon (8 mg), or zolpidem
- Sleep maintenance insomnia (difficulty staying asleep): Consider suvorexant, doxepin (3-6 mg), or eszopiclone
- Both onset and maintenance: Eszopiclone, zolpidem, or temazepam (15 mg) are preferred 1
Step 2: Select Based on Evidence Quality
Recommended medications (supported by American Academy of Sleep Medicine 2017 guidelines):
- Eszopiclone: Effective for both sleep onset and maintenance; doses of 2-3 mg studied 1
- Zolpidem: Effective for both onset and maintenance; 10 mg dose 1
- Suvorexant (orexin receptor antagonist): Specifically for sleep maintenance; 10-20 mg doses 1
- Daridorexant (newer orexin antagonist): Can be used for up to 3 months or longer 2
Alternative options with weaker evidence:
- Ramelteon (8 mg): For sleep onset only; melatonin receptor agonist with better safety profile 1
- Low-dose doxepin (3-6 mg): For sleep maintenance; sedating antidepressant 1
- Temazepam (15 mg): Benzodiazepine for onset and maintenance 1
Step 3: Consider Duration and Safety
Short-term use (≤4 weeks):
- Benzodiazepines and Z-drugs (zolpidem, eszopiclone, zaleplon) are appropriate 2
- These carry risks of cognitive impairment, falls, fractures, and potential dementia with long-term use 3
Longer-term use (>4 weeks):
- Orexin receptor antagonists (suvorexant, daridorexant) can be used for 3+ months 2
- Prolonged-release melatonin for patients ≥55 years, up to 3 months 2
- Consider risks vs. benefits carefully for extended benzodiazepine/Z-drug use 2
Medications to AVOID
Do NOT use the following (negative recommendations from guidelines):
- Trazodone (50 mg): Insufficient evidence despite common off-label use 1
- Diphenhydramine: Not recommended; anticholinergic effects particularly problematic in elderly 1
- Over-the-counter melatonin (2 mg): Insufficient evidence 1
- Tiagabine: Not recommended 1
- L-tryptophan: Not recommended 1
- Valerian: Not recommended 1
- Antihistamines (except doxylamine for ≤4 weeks): Limited evidence, significant side effects 4
- Antipsychotics: Not recommended for insomnia 2
Critical Caveats
Dose adjustments needed:
- Women and older adults require lower doses due to FDA warnings about cognitive impairment and driving risks 3
- Elderly patients have increased risk of falls, fractures, and cognitive decline with hypnotics 3
Important limitations:
- Most evidence comes from short-term trials (weeks to months) in highly selected patients 3
- Long-term efficacy and comparative effectiveness between agents remain unclear 3
- Observational data suggest associations between chronic hypnotic use and dementia, fractures, and major injuries 3
- All pharmacotherapies carry risks of cognitive/behavioral changes including next-day driving impairment 3
Treatment duration:
- Pharmacotherapy should ideally be short-term while addressing underlying causes 2, 5
- Cognitive behavioral therapy for insomnia remains first-line treatment when accessible 2, 5
- Set clear expectations about duration and discontinuation plans before initiating medication 5
Special Populations
Patients ≥55 years: Prolonged-release melatonin is specifically indicated for this age group, replacing physiological decline in endogenous melatonin 2, 6
Comorbid conditions: When insomnia is secondary to psychiatric disorders (depression, anxiety, PTSD), treat the underlying condition while considering specific agents like eszopiclone for comorbid anxiety or depression 7