Recommended Medications for Sleep Onset and Maintenance Insomnia
For insomnia treatment, the American Academy of Sleep Medicine recommends specific medications for sleep onset and maintenance insomnia, with eszopiclone and zolpidem being suggested for both sleep onset and maintenance issues, while other agents are recommended based on specific insomnia subtypes. 1
First-Line Treatment
- Cognitive behavioral therapy for insomnia (CBT-I) should be considered the first-line treatment before pharmacological options 2, 3, 4
- CBT-I produces results equivalent to sleep medication with fewer side effects, less relapse, and continued improvement after treatment ends 4
Medications for Sleep Onset Insomnia
- Zaleplon 10 mg is recommended specifically for difficulty falling asleep 1, 5
- Zolpidem 10 mg is effective for sleep onset issues and has FDA approval 1, 5
- Ramelteon 8 mg is specifically indicated for sleep onset insomnia and has FDA approval 5, 6
- Triazolam 0.25 mg can be used for sleep onset insomnia 1, 5
Medications for Sleep Maintenance Insomnia
- Suvorexant is recommended for sleep maintenance insomnia 1, 7
- Doxepin 3-6 mg is specifically recommended for sleep maintenance issues 8, 5
- Lemborexant (a dual orexin receptor antagonist) is suggested for sleep maintenance insomnia 7, 9
Medications for Both Sleep Onset and Maintenance Insomnia
- Eszopiclone 2-3 mg (1-2 mg for elderly) is effective for both sleep onset and maintenance issues, with FDA approval for both 1, 10
- Zolpidem 10 mg is effective for both sleep onset and maintenance insomnia 1, 5
- Temazepam 15-30 mg (7.5 mg for elderly/debilitated patients) is recommended for both sleep onset and maintenance insomnia 7, 5
Medications NOT Recommended for Insomnia
- Trazodone is not recommended despite common use in clinical practice 5, 10
- Tiagabine is not recommended for sleep onset or maintenance insomnia 10
- Diphenhydramine and other over-the-counter antihistamines are not recommended 6, 5
- Melatonin is not recommended for chronic insomnia despite widespread use 2, 5
- Tryptophan and valerian are not recommended for insomnia treatment 9, 3, 5
Important Clinical Considerations
- All pharmacological recommendations from the AASM are graded as "WEAK" recommendations, reflecting limitations in the evidence quality rather than ineffectiveness 1
- Medication selection should be based on symptom pattern, treatment goals, past treatment responses, comorbidities, and potential side effects 5, 11
- Monitor for next-day residual effects, particularly with eszopiclone 3 mg which has been associated with morning psychomotor and memory impairment 10
- Benzodiazepines and Z-drugs should be used cautiously due to short and long-term risks 9
- Dual orexin receptor antagonists (suvorexant, lemborexant) represent newer options with effectiveness for sleep maintenance 7, 9
Follow-Up and Monitoring
- Regular follow-up (every few weeks initially) is essential to assess effectiveness, side effects, and need for ongoing medication 5
- Pharmacological treatment should be supplemented with behavioral and cognitive therapies when possible 5, 3
- Patient education should include treatment goals, safety concerns, potential side effects, and drug interactions 5