What are the best sleep medications for treating insomnia?

Best Medications for Treating Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for chronic insomnia, with pharmacotherapy reserved for those who fail to respond adequately to CBT-I. 1

Treatment Algorithm

1. First-line approach: Non-pharmacological

   • CBT-I is strongly recommended by both the American Academy of Sleep Medicine and American College of Physicians due to superior long-term efficacy and minimal side effects 1
   • CBT-I components include sleep restriction therapy, stimulus control, cognitive therapy, relaxation techniques, and sleep hygiene education
   • Can be delivered through individual therapy, group therapy, or self-help formats

2. Second-line approach: Pharmacotherapy based on insomnia type

   For sleep onset insomnia:

   • Zolpidem 10mg (5mg in elderly) 1, 2
   • Zaleplon 10mg 1
   • Ramelteon 8mg 1, 3

   For sleep maintenance insomnia:

   • Eszopiclone 2-3mg 1, 4
   • Doxepin 3-6mg 1
   • Temazepam 15mg 1
   • Suvorexant 10-20mg 1

Special Populations

Elderly Patients (≥65 years)

• Use lower doses of all medications 1
• Avoid benzodiazepines due to increased risk of falls and cognitive impairment 1
• Safer alternatives:
  • Ramelteon 8mg 1, 3
  • Low-dose doxepin (3mg) 1
  • Melatonin PR 2mg has shown efficacy in patients ≥55 years with good tolerability profile and no impairment of psychomotor functions 5

Patients with Substance Use History

• Prefer non-scheduled options:
  • Ramelteon 1, 3
  • Doxepin 1

Medication Considerations

Z-drugs (Zolpidem, Zaleplon, Eszopiclone)

• Effective for short-term treatment 4, 2
• Monitor for:
  • Complex sleep behaviors
  • Next-day impairment
  • CNS depression
  • Signs of tolerance or dependence
  • Falls risk, particularly in elderly 1

Melatonin

• Low likelihood of adverse effects and drug-drug interactions 6
• No dependence, tolerance, rebound insomnia or withdrawal symptoms 5
• Effective doses vary by age group:
  • Adults: 1-5mg
  • Elderly: 1-6mg 7
• Prolonged-release formulation (2mg) mimics natural secretion pattern 5

Monitoring and Follow-up

• Assess sleep parameters within 2-4 weeks of starting any treatment 1
• Monitor for side effects, particularly daytime sedation, falls, and cognitive changes 1
• Schedule follow-up within 2-4 weeks to evaluate effectiveness and adjust treatment 1
• Consider referral to sleep specialist if insomnia persists 1, 8

Important Caveats

• Most hypnotic medications are indicated for short-term use only 2
• FDA-approved medications have stronger evidence than over-the-counter supplements
• Benzodiazepines should be avoided in elderly due to risk of falls, cognitive impairment, and dependence 1, 6
• Sleep hygiene education alone is minimally effective and should be incorporated as part of a comprehensive CBT-I program 1