What are the recommended medications and dosages for treating difficulty sleeping?

Recommended Medications for Insomnia

For treating insomnia, first-line treatment should be cognitive behavioral therapy for insomnia (CBT-I), with pharmacological options considered as second-line treatment when CBT-I is insufficient or unavailable. 1, 2

Non-Pharmacological First-Line Treatment

• CBT-I should be the initial intervention for all patients with insomnia, including components such as stimulus control therapy, sleep restriction therapy, and cognitive therapy 1, 2
• Sleep hygiene alone is insufficient but should be used in combination with other therapies 1, 2
• Other effective behavioral interventions include paradoxical intention and biofeedback therapy 1
• Relaxation therapy can be beneficial as part of a multicomponent approach 1, 3

Pharmacological Treatment Algorithm

For Sleep Onset Insomnia (Difficulty Falling Asleep)

• First-line options:
  • Zaleplon 10 mg (5 mg in elderly/hepatic impairment) 1, 2
  • Zolpidem 10 mg (5 mg in elderly) 1, 2
  • Ramelteon 8 mg (specifically for sleep onset) 1, 4
  • Triazolam 0.25 mg (0.125 mg in elderly) 1, 2

For Sleep Maintenance Insomnia (Difficulty Staying Asleep)

• First-line options:
  • Doxepin 3-6 mg (specifically targets sleep maintenance with minimal side effects) 2, 5
  • Eszopiclone 2-3 mg (1 mg in elderly) 1, 6
  • Zolpidem CR 12.5 mg (6.25 mg in elderly) 1, 2
  • Temazepam 15-30 mg (7.5 mg in elderly) 1, 2
  • Suvorexant 10-20 mg 5

Medication Selection Considerations

• Choose medications based on 1, 2:
  • Primary symptom pattern (sleep onset vs. maintenance)
  • Treatment goals
  • Past treatment responses
  • Patient preference
  • Comorbid conditions
  • Potential side effects and drug interactions

Duration and Monitoring

• Follow patients regularly (every few weeks initially) to assess effectiveness and side effects 1, 2
• Use the lowest effective maintenance dosage and taper when possible 1
• Pharmacological treatment should be supplemented with behavioral therapies 1, 2

Medications Not Recommended

• Over-the-counter antihistamines (diphenhydramine) are not recommended for chronic insomnia 1, 2
• Melatonin, valerian, and L-tryptophan lack sufficient efficacy data for chronic insomnia 1, 2
• Barbiturates and chloral hydrate are not recommended due to safety concerns 1
• Trazodone (50 mg) is not recommended despite common clinical use 2, 5

Important Cautions

• Benzodiazepines and Z-drugs (zolpidem, eszopiclone, zaleplon) may cause daytime memory and psychomotor impairment, abnormal thinking, and complex behaviors like sleep driving 1, 6
• Ramelteon may cause somnolence, fatigue, dizziness, and nausea in about 3-4% of patients 4
• Older adults should receive lower doses of all sleep medications due to increased sensitivity and risk of side effects 1, 2
• Short-term hypnotic treatment should be supplemented with behavioral therapies 1, 7

Patient Education

• Provide information about treatment goals, safety concerns, potential side effects, drug interactions, and potential for rebound insomnia 1, 2
• Emphasize that medications should be used at the lowest effective dose for the shortest duration possible 1, 2