What are the treatment options for patients with parasomnia, hypersomnia, or insomnia?

Treatment Options for Parasomnia, Hypersomnia, and Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment for insomnia, while specific behavioral and pharmacological approaches are recommended for parasomnias and hypersomnias based on their specific subtypes. 1

Insomnia Treatment

First-Line: Behavioral and Psychological Approaches

• CBT-I is the most effective treatment for chronic insomnia and should be utilized as the initial intervention whenever possible 1
• CBT-I components include sleep restriction therapy, stimulus control, and cognitive therapy to address distorted beliefs about sleep 1
• Brief Behavioral Therapies for Insomnia (BTIs) are effective alternatives when full CBT-I is not available 1
• Single-component therapies that are effective include:
  • Stimulus control therapy (establishing a consistent sleep-wake schedule) 1
  • Sleep restriction therapy (limiting time in bed to match actual sleep time) 1
  • Relaxation training (progressive muscle relaxation, deep breathing) 1

Second-Line: Pharmacological Approaches

• When pharmacotherapy is necessary, follow this sequence 1:

  1. Short-intermediate acting benzodiazepine receptor agonists (zolpidem, eszopiclone, zaleplon) or ramelteon
  2. Alternate BzRAs if first agent unsuccessful
  3. Sedating antidepressants (trazodone 25-50mg, doxepin 3-6mg, amitriptyline, mirtazapine)
  4. Combined BzRA and sedating antidepressant
  5. Other sedating agents (gabapentin, tiagabine, quetiapine, olanzapine)

• Short-term hypnotic treatment should always be supplemented with behavioral and cognitive therapies 1

• Over-the-counter sleep aids and herbal supplements are not recommended due to lack of efficacy and safety data 1

Hypersomnia Treatment

Diagnostic Approach

• Hypersomnias of central origin typically require overnight polysomnography followed by multiple sleep latency testing (MSLT) 1
• MRI of the brain may be necessary to identify neurological causes of hypersomnia 1

Treatment Options

• Behavioral modifications:

  • Maintain regular sleep-wake schedule with adequate nighttime sleep 1
  • Schedule two short 15-20 minute naps (noon and late afternoon) 1
  • Avoid heavy meals, alcohol, and shift work 1

• Pharmacological treatment:

  • Modafinil is first-line for narcolepsy and other hypersomnias (starting at 100mg in elderly patients) 1, 2
  • Traditional stimulants (methylphenidate, amphetamines) may be used if modafinil is ineffective 1
  • For cataplexy: antidepressants or sodium oxybate 1

Parasomnia Treatment

General Approach

• Treatment depends on parasomnia subtype, frequency, and associated risks 3, 4
• Many parasomnias are benign and require only reassurance and sleep hygiene education 4, 5

Specific Treatments

• For NREM parasomnias (sleepwalking, night terrors):

  • Safety measures to prevent injury 3
  • Scheduled awakenings 15-30 minutes before typical episode 3
  • Clonazepam for persistent, dangerous episodes 3

• For REM parasomnias (REM behavior disorder):

  • Clonazepam is the first-line treatment 3, 4
  • Melatonin may be effective in some cases 3

• For nightmares:

  • Imagery rehearsal therapy and cognitive restructuring 6, 3
  • Prazosin (alpha-blocker) for trauma-related nightmares 6, 3

Important Considerations and Pitfalls

• Sleep disorders often coexist; multiple primary and comorbid disorders may be present simultaneously 1
• Treatment goals should focus on improving sleep quality/quantity and reducing daytime impairments 1
• Regular reassessment is essential as relapse rates for insomnia are high; follow-up every few weeks initially, then every 6 months 1
• Avoid long-term use of benzodiazepines due to dependence risk, abuse potential, and cognitive impairment 6
• Sleep hygiene alone is insufficient for treating chronic insomnia but should be included as part of comprehensive treatment 1
• When treating hypersomnias, start with lower medication doses in elderly patients and monitor for side effects 1
• Video-polysomnography may be necessary to correctly diagnose complex or injurious parasomnias 5