What medications help with insomnia?

Medications for Insomnia Treatment

For patients with chronic insomnia, the recommended first-line pharmacological treatments are short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon, followed by sedating antidepressants if initial treatments are unsuccessful. 1, 2

First-Line Pharmacological Options

• Short-intermediate acting benzodiazepine receptor agonists (BzRAs):

  • Zolpidem (10mg, 5mg in elderly) - effective for both sleep onset and maintenance insomnia 2, 3
  • Eszopiclone (2-3mg) - effective for both sleep onset and sleep maintenance insomnia 2, 4
  • Zaleplon (10mg) - specifically for sleep onset insomnia 2
  • Temazepam (15mg) - effective for both sleep onset and maintenance insomnia 2

• Ramelteon (8mg) - specifically for sleep onset insomnia 2, 5

Second-Line Pharmacological Options

• Sedating antidepressants (especially when comorbid depression/anxiety exists):

  • Trazodone (though not specifically recommended for primary insomnia) 1, 2
  • Amitriptyline 1
  • Doxepin (3-6mg) - particularly effective for sleep maintenance insomnia 2, 6
  • Mirtazapine 1

• Suvorexant (orexin receptor antagonist) - for sleep maintenance insomnia 2

• Combined therapy: BzRA or ramelteon plus sedating antidepressant 1

Medication Selection Algorithm

1. For sleep onset difficulty:

   • Consider zaleplon, ramelteon, zolpidem, or eszopiclone 2, 6
   • Zaleplon and ramelteon have minimal next-day effects due to their shorter half-lives 2, 7

2. For sleep maintenance difficulty:

   • Consider eszopiclone, zolpidem, temazepam, doxepin, or suvorexant 2, 6
   • Low-dose doxepin (3-6mg) is particularly effective for the latter third of the night 8

3. For both onset and maintenance issues:

   • Consider eszopiclone, zolpidem, or temazepam 2, 9

Important Clinical Considerations

• Pharmacological treatment should be supplemented with cognitive behavioral therapy for insomnia (CBT-I) whenever possible 1, 2

• The choice of medication should be guided by:

  • Symptom pattern (onset vs. maintenance insomnia) 1
  • Treatment goals 1
  • Past treatment responses 1
  • Patient factors (age, comorbidities) 2
  • Potential drug interactions 1

• Use the lowest effective dose, especially in elderly patients 1, 10

• Regular follow-up is essential to assess effectiveness and monitor for side effects 1

Medications Not Recommended

• Over-the-counter antihistamines (e.g., diphenhydramine) - lack of efficacy data and safety concerns 1, 2
• Herbal supplements (e.g., valerian) and melatonin - insufficient evidence of efficacy 1, 2
• Older hypnotics including barbiturates and chloral hydrate 1
• Tiagabine (anticonvulsant) is not recommended for insomnia 2

Common Pitfalls to Avoid

• Using sedating agents without considering their specific effects on sleep onset versus maintenance 2
• Failing to consider the risk of tolerance, dependence, and rebound insomnia, particularly with benzodiazepines 10
• Using medications long-term without periodic reassessment and attempts at discontinuation 1
• Not accounting for pharmacokinetic differences in special populations (e.g., elderly patients may need lower doses due to slower drug metabolism) 10
• Overlooking potential for complex behaviors with zolpidem (sleepwalking, sleep-driving) 10