What is the best herbal treatment for insomnia?

Best Herbal Treatment for Insomnia

Valerian has small but consistent effects on sleep latency, but is not recommended as first-line treatment for insomnia due to inconsistent effects on sleep continuity and limited high-quality evidence supporting its efficacy. 1

Evidence on Herbal Treatments for Insomnia

Valerian

• Valerian shows modest effects on subjective sleep quality but inconsistent effects on sleep continuity, duration, and architecture 1
• Recent high-quality studies and systematic reviews show no significant evidence of efficacy for treating insomnia 2, 3
• A 2024 umbrella review concluded that despite widespread use, valerian lacks empirical support for insomnia treatment 2
• Earlier meta-analyses suggested possible benefits (relative risk of improved sleep = 1.8), but publication bias was noted in these findings 4
• Valerian appears to have a good safety profile with rare adverse events 3

Melatonin

• Meta-analyses demonstrate melatonin has small effects on sleep latency but little effect on wake after sleep onset (WASO) or total sleep time (TST) 1
• Evidence for melatonin's efficacy is considered inconclusive by multiple guidelines 1
• Some studies evaluated melatonin as a chronobiotic (phase-shifting agent) rather than as a hypnotic 1

Guideline Recommendations

First-Line Approaches

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is strongly recommended as first-line treatment for chronic insomnia 1, 5
• Pharmacotherapy should be considered mainly for patients unable to participate in CBT-I or who have persistent symptoms despite CBT-I 1

Recommendations on Herbal Treatments

• Over-the-counter herbal substances (including valerian and melatonin) are not recommended for treating chronic insomnia due to relative lack of efficacy and safety data 1
• Long-term use of non-prescription treatments is not recommended as efficacy and safety data are limited to short-term studies 1
• The U.S. Food and Drug Administration recommends against using herbal supplements like kava for insomnia due to lack of proven efficacy and potential safety concerns 5

Safety Considerations for Herbal Treatments

• While valerian appears to have fewer side effects compared to many prescription sleep medications, its efficacy remains questionable 3, 6
• Aqueous extracts and low-titre hydro-alcoholic preparations of valerian are preferable to high-titre alcoholic extracts or powdered valerian root 6
• Herbal supplements may interact with other medications and should be discussed with healthcare providers 5
• A phase III, double-blinded trial of Valerian (450 mg) compared with placebo in cancer patients showed no effect on sleep quality 1

Recommended Treatment Algorithm for Insomnia

1. Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment 1, 5
2. If pharmacotherapy is needed, consider prescription options like short-intermediate acting benzodiazepine receptor agonists or ramelteon 1
3. For those interested in herbal options despite limited evidence:
   • Valerian may provide modest subjective improvements in sleep quality 4, 6
   • Choose standardized aqueous extracts rather than alcoholic preparations 6
   • Monitor for effectiveness and discontinue if no benefit is observed 1
   • Do not use for long-term treatment due to lack of safety data 1

In conclusion, while valerian shows the most evidence among herbal treatments for insomnia, the quality of evidence remains low, and guidelines consistently recommend CBT-I as the first-line approach for insomnia management.