What is the best medication for insomnia?

Best Medication for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be used as first-line treatment for all adults with chronic insomnia, with pharmacological therapy reserved as second-line treatment only when CBT-I alone is unsuccessful. 1, 2, 3

First-Line Treatment: CBT-I

• CBT-I has demonstrated superior long-term efficacy compared to pharmacological options and carries minimal risk of adverse effects 3
• Key components include stimulus control, sleep restriction therapy, cognitive therapy, sleep hygiene education, and relaxation techniques 3
• Collection of sleep diary data before and during treatment is recommended to monitor progress 3

Second-Line Treatment: Pharmacological Options

When CBT-I is insufficient after an adequate trial (4-8 weeks), consider the following medications based on symptom pattern:

For Sleep Onset Insomnia:

• Short-acting non-benzodiazepines:
  • Zaleplon 10 mg (5 mg in elderly/debilitated) - shortest acting 1
  • Zolpidem 10 mg (5 mg in elderly) 1, 4
• Melatonin receptor agonist:
  • Ramelteon 8 mg - particularly useful for patients with substance use history due to lower abuse potential 1, 2

For Sleep Maintenance Insomnia:

• Intermediate-acting non-benzodiazepines:
  • Eszopiclone 2-3 mg (1 mg in elderly/debilitated) 1, 5
  • Zolpidem CR 12.5 mg (6.25 mg in elderly) 6
• Low-dose doxepin (3-6 mg) - particularly effective for sleep maintenance issues 1, 3

For Both Sleep Onset and Maintenance:

• Benzodiazepines:
  • Temazepam 15-30 mg (7.5 mg in elderly) - short to intermediate-acting 6, 1
  • Estazolam 1-2 mg (0.5 mg in elderly) - short to intermediate-acting 6

Medication Selection Algorithm

1. Identify primary symptom pattern (onset vs. maintenance insomnia)
2. Consider patient factors:
   • Age (lower doses for elderly)
   • Comorbidities (avoid benzodiazepines with respiratory disorders)
   • Risk of abuse/dependence (avoid benzodiazepines if substance use history)
   • Previous treatment response
   • Cost and patient preference 1, 3
3. Start with lowest effective dose and shortest duration (ideally ≤4-5 weeks) 2, 3
4. Continue incorporating behavioral techniques even when using medications 2

Important Clinical Considerations

• FDA has approved pharmacologic therapy for short-term use only (4-5 weeks) 2
• Monitor for adverse effects including:
  • Residual sedation and daytime impairment
  • Memory and performance impairment
  • Falls and injuries (especially in elderly)
  • Behavioral abnormalities including "sleep driving" 3, 4, 5
• Avoid benzodiazepines in patients with substance use disorders due to high abuse potential 3
• Antihistamines (e.g., diphenhydramine) and herbal supplements (e.g., valerian) are not recommended due to lack of efficacy data and safety concerns 1

Common Pitfalls to Avoid

• Using sedating agents without considering their specific effects on sleep onset versus maintenance 1
• Failing to consider drug interactions and contraindications 1
• Using over-the-counter sleep aids with limited efficacy data 1, 3
• Continuing pharmacotherapy long-term without periodic reassessment 1, 3
• Neglecting to implement CBT-I techniques alongside medication 2, 7, 8