What is better for sleep, trazodone or amitriptyline?

Trazodone vs. Amitriptyline for Sleep

Based on current guidelines, neither trazodone nor amitriptyline is recommended as a first-line treatment for insomnia, with trazodone specifically receiving a weak recommendation against its use for sleep onset or maintenance insomnia. 1

Guideline Recommendations

The American Academy of Sleep Medicine (AASM) explicitly recommends against using trazodone for sleep onset or maintenance insomnia in adults 1. Their recommendation is based on clinical trials showing that:

• Trazodone 50mg produced only modest reductions in sleep latency below clinical significance thresholds
• Increases in total sleep time were clinically insignificant (21.8 minutes)
• Reductions in wake time after sleep onset were below clinical significance thresholds
• Sleep quality improvements were not significant versus placebo

Additionally, trazodone was associated with more side effects than placebo, including:

• Headache (30% vs 19% for placebo)
• Somnolence (23% vs 8% for placebo)
• 75% of trazodone subjects reported some adverse events compared to 65.4% on placebo 1

Preferred Treatments for Insomnia

Current guidelines strongly recommend:

1. Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment, which should be tried for 4-8 weeks before considering medication 2

2. If pharmacotherapy is needed, the following medications are recommended:

   • For sleep onset insomnia: ramelteon (8mg), zolpidem (10mg adults, 5mg elderly), zaleplon (10mg)
   • For sleep maintenance insomnia: low-dose doxepin (3-6mg), eszopiclone (2-3mg), suvorexant (10-20mg) 2

Comparing Trazodone and Amitriptyline

While the AASM specifically recommends against trazodone for insomnia, there is limited evidence in the guidelines regarding amitriptyline for insomnia:

• The Cochrane review found no studies of amitriptyline for insomnia despite its common use in clinical practice 3
• Trazodone has been studied at 50-100mg doses for sleep disorders, with 100mg showing better improvement 4
• Both medications have sedating properties, with amitriptyline often being as sedating as trazodone 5

Side Effect Considerations

Both medications have important side effect profiles to consider:

• Trazodone: Headache, somnolence, morning grogginess, dry mouth and thirst 1, 3
• Amitriptyline: More pronounced anticholinergic effects than trazodone (dry mouth, constipation, urinary retention, blurred vision) 5
• Both can cause daytime sedation, but this may be reduced by bedtime dosing 5

Practical Recommendations

Given the evidence:

1. Neither medication is ideal for insomnia treatment based on current guidelines
2. If choosing between these two specifically:
   • For patients sensitive to anticholinergic side effects, trazodone may be preferable
   • For patients with depression and insomnia, either medication could be considered at therapeutic doses
   • Trazodone dosing at 50-100mg at bedtime has some evidence for sleep improvement 4

Important Caveats

• Both medications should be used at the lowest effective dose
• Monitor for side effects, particularly daytime sedation and cognitive changes
• Consider referral to a sleep specialist if insomnia persists
• Neither medication is FDA-approved specifically for insomnia
• Both medications should be considered only after CBT-I has been attempted 2