What medications are recommended to help with insomnia?

Medications for Insomnia Management

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be recommended as the first-line treatment for chronic insomnia before considering medication options. 1, 2

First-Line Treatment Approach

1. Non-Pharmacological Treatment (First-Line)
   • CBT-I is the most effective initial treatment for chronic insomnia with strong evidence supporting its efficacy 1
   • CBT-I components include:
     • Cognitive therapy addressing unhelpful sleep beliefs
     • Behavioral interventions (sleep restriction, stimulus control)
     • Sleep hygiene education
   • CBT-I can be delivered through various methods:
     • Individual or group therapy
     • Telephone or web-based modules
     • Self-help books

Pharmacological Options (Second-Line)

When medications are necessary after trying or alongside CBT-I, the following are recommended based on insomnia type:

For Sleep Onset Insomnia:

• Zolpidem: 10mg for adults, 5mg for elderly 2
• Zaleplon: 10mg 2
• Ramelteon: 8mg - FDA-approved for sleep onset difficulties with lower abuse potential 3

For Sleep Maintenance Insomnia:

• Doxepin (low-dose): 3-6mg - non-habit forming with minimal next-day sedation 2
• Eszopiclone: 2-3mg - shown to improve sleep maintenance 2, 4
• Temazepam: 15mg 2
• Suvorexant: 10-20mg - shown to improve response to therapy (55% vs 42% with placebo) 2

Special Considerations

Elderly Patients

• Use lower doses (e.g., eszopiclone 1mg, suvorexant 5mg) due to increased fall risk 2
• Ramelteon 4-8mg has shown efficacy in older adults with fewer side effects 2, 3

Patients with Substance Use History

• Prefer non-scheduled options like low-dose doxepin 2
• Ramelteon has shown no abuse potential even at 20 times the therapeutic dose 3

Patients with Respiratory Conditions

• Avoid benzodiazepines due to risk of respiratory depression 2

Medication Cautions

• FDA warnings for benzodiazepine and non-benzodiazepine hypnotics include:

  • Cognitive and behavioral changes
  • Potential driving impairment
  • Risk of motor vehicle accidents 1

• Serious adverse effects associated with hypnotic drugs may include:

  • Dementia
  • Fractures
  • Next-day impairment 1

• The FDA recommends short-term use of these medications, though many patients continue them for extended periods 1

Monitoring and Follow-up

• Assess sleep parameters within 2-4 weeks of starting any treatment 2
• Monitor for side effects, particularly:
  • Daytime sedation
  • Falls
  • Cognitive changes 2

Not Recommended Treatments

The following are not recommended for insomnia treatment:

• Trazodone for sleep onset insomnia 2
• Diphenhydramine 2
• Melatonin (except prolonged release formulations) 2
• Valerian 2
• Tiagabine 2
• Tryptophan 2

Remember that while medications may provide short-term relief, CBT-I produces sustained benefits without the risk for tolerance or adverse effects associated with pharmacologic approaches, making it the preferred first-line treatment for chronic insomnia.