What are the treatment options for acute insomnia?

Treatment Options for Acute Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as the first-line treatment for acute insomnia, with pharmacological options considered as second-line treatments when CBT-I is ineffective or while waiting for CBT-I to take effect. 1

Non-Pharmacological Interventions

First-Line Treatment: CBT-I and Behavioral Therapies

• CBT-I produces clinically significant improvements in sleep quality and quantity with long-term efficacy without the risks associated with medications 1
• When full CBT-I is not available, the following single behavioral therapies are recommended:
  • Stimulus Control (strongest evidence) 1
  • Progressive Muscle Relaxation 1
  • Sleep Restriction Therapy 1

Supportive Non-Pharmacological Approaches

• Morning light exposure (2,500-5,000 lux for 1-2 hours) 1
• Regular daytime physical activity (avoiding exercise within 3 hours of bedtime) 1
• Structured bedtime routine 1
• Decreased nighttime noise and light 1

Important Clinical Considerations

• Patients should be informed that psychological and behavioral therapies typically produce gradual improvements rather than immediate relief 2
• Initial side effects like sleepiness and fatigue are typically mild and resolve quickly for most patients 2
• Sleep hygiene education alone is not recommended as a standalone treatment due to lack of evidence for efficacy 2, 1

Pharmacological Options (Second-Line)

For Sleep Onset Insomnia

• Ramelteon 8mg - FDA-approved for sleep onset insomnia with favorable safety profile 1, 3
• Zolpidem 10mg (5mg for elderly) 1
• Zaleplon 10mg 1

For Sleep Maintenance Insomnia

• Doxepin 3-6mg 1
• Eszopiclone 2-3mg 1
• Temazepam 15mg - effective but carries risks of dependence and withdrawal 1, 4
• Suvorexant 10-20mg 1

Alternative Options

• Melatonin 3-5mg taken 30-60 minutes before bedtime (can be titrated up to 15mg if needed) 1

Common Pitfalls to Avoid

• Relying solely on sleep hygiene education without implementing full CBT-I or other behavioral therapies 2, 1
• Prescribing medications as first-line treatment instead of CBT-I 1
• Long-term use of benzodiazepines, which can lead to dependence, tolerance, and withdrawal symptoms 4
• Using antihistamines (except doxylamine) as evidence for their efficacy is generally lacking 1
• Overlooking potential for complex behaviors with sedative-hypnotics (e.g., "sleep-driving") 4

Treatment Monitoring

• Follow up within 2-4 weeks of any intervention 1
• Assess for daytime impairment and side effects 1
• Use standardized sleep assessment tools to track progress 1
• For medications, aim for the lowest effective dose and shortest duration of treatment 1, 4

Special Considerations

• For elderly patients: Use lower starting doses and slower titration of medications 1
• For patients with comorbid conditions: Consider how sleep deprivation might affect conditions like seizure disorders or bipolar disorder 2
• Benzodiazepines should be tapered gradually when discontinuing to prevent withdrawal reactions 4

When treating acute insomnia, start with CBT-I or behavioral interventions, reserving medications for cases where these approaches are insufficient or while waiting for behavioral therapies to take effect.