What allergy medication is recommended for individuals with insomnia?

Allergy Medications for Insomnia

First-generation antihistamines may be considered for short-term use in insomnia due to their sedative properties, but they are not recommended for chronic insomnia treatment due to limited efficacy and safety data. 1

First-Line Treatments for Insomnia

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should be utilized as the initial intervention for chronic insomnia when appropriate and conditions permit 1
• When pharmacological treatment is necessary, the recommended sequence begins with short-intermediate acting benzodiazepine receptor agonists (BzRAs) such as zolpidem, eszopiclone, zaleplon, or temazepam 1, 2
• Melatonin receptor agonists like ramelteon are also considered appropriate first-line pharmacological options 1, 2

Role of Antihistamines in Insomnia Treatment

First-Generation Antihistamines

• First-generation antihistamines have significant sedative properties that may occasionally be advantageous for sleep induction when taken at bedtime 1
• These medications are commonly used in over-the-counter (OTC) "sleep aids" but are not recommended for chronic insomnia treatment due to limited efficacy and safety data 1
• Diphenhydramine, a common first-generation antihistamine, shows some evidence of effectiveness for acute insomnia but carries risks of next-day impairment 3, 4
• First-generation antihistamines have anticholinergic properties that can cause significant side effects, particularly in older adults 1, 2

Second-Generation Antihistamines

• Second-generation antihistamines are generally preferred over first-generation antihistamines for treating allergic rhinitis due to their reduced sedative effects 1
• There are important differences among second-generation antihistamines regarding sedative properties:
  • Fexofenadine, loratadine, and desloratadine do not cause sedation at recommended doses 1
  • Loratadine and desloratadine may cause sedation at doses exceeding recommended amounts 1
  • Cetirizine and intranasal azelastine may cause sedation at recommended doses 1, 5

Treatment Algorithm for Insomnia

1. Start with CBT-I as first-line treatment 1
2. If pharmacotherapy is needed:
   • For short-term/acute insomnia: Consider short-intermediate acting BzRAs or ramelteon 1, 2
   • If allergic symptoms are also present: A first-generation antihistamine may be considered for very short-term use only 1, 3
3. For chronic insomnia requiring medication:
   • Avoid first-generation antihistamines and OTC sleep aids 1
   • Consider sedating antidepressants (trazodone, amitriptyline, doxepin, mirtazapine) if BzRAs are ineffective or contraindicated 1, 2

Cautions and Considerations

• First-generation antihistamines can cause significant daytime sedation, performance impairment, and anticholinergic effects 1, 4
• Antihistamines with high blood-brain barrier penetration (like diphenhydramine and ketotifen) show stronger carryover effects on next-day alertness and psychomotor performance 4
• In older adults, first-generation antihistamines should be used with extreme caution due to increased risk of anticholinergic effects, cognitive impairment, and falls 1, 2
• Long-term use of antihistamines for insomnia may lead to tolerance of sedative effects 6

Special Populations

• For older adults: Lower doses of approved hypnotics are preferred over antihistamines; first-generation antihistamines should generally be avoided 1, 2
• For patients with comorbid allergic rhinitis and insomnia: Consider the sedative properties of certain antihistamines as potentially beneficial, but prioritize treating the underlying allergic condition with appropriate medications 1, 2

Monitoring and Follow-up

• Patients using any medication for insomnia should be followed regularly to assess effectiveness, side effects, and need for ongoing treatment 1
• Efforts should be made to use the lowest effective dose and to taper medication when conditions allow 1