From the Guidelines
Chronic insomnia is best treated with Cognitive Behavioral Therapy for Insomnia (CBT-I) as the first-line treatment, which has proven more effective long-term than medications alone. This approach involves sleep restriction, stimulus control, relaxation techniques, and addressing unhelpful thoughts about sleep 1. For those needing medication, options include non-benzodiazepines like zolpidem (Ambien) 5-10mg, eszopiclone (Lunesta) 1-3mg, or zaleplon (Sonata) 5-10mg taken 30 minutes before bedtime for short-term use (2-4 weeks ideally) 1. Melatonin (1-5mg) can help regulate sleep cycles with fewer side effects 1. Trazodone (25-100mg) is sometimes prescribed off-label. Lifestyle changes are crucial:
- maintaining consistent sleep-wake times
- avoiding caffeine after noon
- limiting alcohol
- creating a dark and cool bedroom environment
- avoiding screens before bed
- exercising regularly but not within 3 hours of bedtime. These medications work by enhancing GABA activity in the brain or regulating sleep hormones, but can cause side effects including dependence, which is why behavioral approaches should be prioritized for sustainable improvement. According to the American Academy of Sleep Medicine, CBT-I is the treatment of choice, with a strong recommendation based on moderate-quality evidence 1.
From the FDA Drug Label
Ramelteon tablets are indicated for the treatment of insomnia characterized by difficulty with sleep onset. Zolpidem was evaluated in two controlled studies for the treatment of patients with chronic insomnia (most closely resembling primary insomnia, as defined in the APA Diagnostic and Statistical Manual of Mental Disorders, DSM-IV™)
The treatment options for chronic insomnia include:
- Ramelteon (PO): indicated for the treatment of insomnia characterized by difficulty with sleep onset 2, 2
- Zolpidem (PO): evaluated in two controlled studies for the treatment of patients with chronic insomnia 3 Key points:
- Ramelteon reduces sleep latency at each time point when compared to placebo 2
- Zolpidem 10 mg was superior to placebo on a subjective measure of sleep latency for all 4 weeks, and on subjective measures of total sleep time, number of awakenings, and sleep quality for the first treatment week 3
From the Research
Treatment Options for Chronic Insomnia
The following treatment options are available for chronic insomnia:
- Cognitive-behavioral therapy for insomnia (CBT-i) 4, 5, 6, 7
- Stimulus control therapy 4
- Relaxation training 4
- Sleep restriction therapy 4
- Multicomponent therapy (without cognitive therapy) 4
- Biofeedback 4
- Paradoxical intention 4
- Sleep hygiene education 8, 6, 7
- Progressive muscle relaxation 8
- Physical exercise practices 8
Non-Pharmacological Treatment Approaches
Non-pharmacological treatment approaches are effective in the treatment of chronic insomnia, including:
- Behavioral approaches 8
- Cognitive approaches 5, 6, 7
- Complementary and alternative medicine (CAM) approaches 5
Effectiveness of Treatment Options
The effectiveness of these treatment options is well established, with cognitive-behavioral therapies comparing favorably to pharmacologic approaches 5, 6, 7. CBT-i is considered an evidence-based treatment for insomnia, with results equivalent to sleep medication and no side effects 7.