What are the treatments for daytime drowsiness?

Treatment of Daytime Drowsiness

The treatment of daytime drowsiness depends critically on identifying and treating the underlying cause—if due to insomnia, use cognitive-behavioral therapy for insomnia (CBT-I) as first-line treatment; if due to obstructive sleep apnea (OSA), use continuous positive airway pressure (CPAP); and for residual sleepiness despite optimal treatment of OSA, consider modafinil or armodafinil. 1, 2

Identify the Underlying Cause

The most common causes of daytime drowsiness requiring specific treatment approaches include:

• Sleep deprivation/chronic insomnia disorder: Characterized by difficulty falling asleep, staying asleep, or early morning awakenings with associated daytime impairment 1
• Obstructive sleep apnea: Excessive sleepiness with frequent episodes of impaired breathing during sleep, loud snoring, morning headaches 1
• Sedating medications: Review all current medications for sedating effects 3
• Central disorders of hypersomnolence: Narcolepsy, idiopathic hypersomnia (less common) 4

Treatment Algorithm by Cause

For Daytime Drowsiness Due to Chronic Insomnia

Cognitive-behavioral therapy for insomnia (CBT-I) is the first-line treatment and should be strongly recommended over pharmacologic therapy. 1

CBT-I components include:

• Sleep restriction therapy (limiting time in bed to actual sleep time, then gradually increasing) 1
• Stimulus control (strengthening association between bed and sleep, establishing consistent sleep patterns) 1
• Relaxation therapy and counterarousal strategies 1
• Cognitive therapy targeting maladaptive beliefs about sleep 1
• Sleep hygiene education 1

Key implementation points:

• CBT-I demonstrates clinically significant improvements in sleep quality, sleep latency, wake after sleep onset, and remission rates with moderate-quality evidence 1
• Treatment gains are durable long-term without additional intervention 1
• Multiple delivery formats are effective: in-person one-on-one, group therapy, telephone, self-help, and Internet-based delivery 1

Important caveats about CBT-I:

• Temporary worsening of daytime sleepiness occurs during early treatment phases (first 2-4 weeks), particularly with sleep restriction therapy 1
• Warn patients about dangers of drowsy driving during initial treatment 1
• Sleep restriction may be contraindicated in those working with heavy machinery, drivers, or those predisposed to mania/hypomania or poorly controlled seizures 1
• Risk of nighttime falls in older adults or those on sleep medications when following stimulus control instructions 1
• These adverse effects typically resolve by end of treatment 1

Brief therapies for insomnia (BTIs) can be used as an alternative when resources are limited, delivered over 2-4 sessions focusing on behavioral components only 1

For Daytime Drowsiness Due to Obstructive Sleep Apnea

All overweight and obese patients with OSA should be strongly encouraged to lose weight as obesity is a major risk factor and weight loss reduces apnea-hypopnea index (AHI) scores 1

CPAP therapy is the first-line treatment for OSA with excessive daytime sleepiness:

• CPAP improves Epworth Sleepiness Scale (ESS) scores, reduces AHI and arousal index, and increases oxygen saturation 1
• Use CPAP for the entirety of the sleep period 1
• Continue CPAP even if used less than 4 hours per night, as some benefit occurs even with suboptimal adherence 1
• Provide supportive, educational, and behavioral interventions early to improve adherence 1
• Greater AHI and ESS scores at baseline predict better CPAP adherence 1

Mandibular advancement devices (MADs) are an alternative for patients who prefer them or cannot tolerate CPAP 1

• MADs are less effective than CPAP in reducing AHI but may have similar overall benefits due to better adherence 1
• Consider MADs for patients with AHI scores between 18-40 events per hour who have CPAP adverse effects 1

For Residual Daytime Sleepiness Despite Optimal OSA Treatment

When sleepiness persists after optimizing CPAP therapy (documented CPAP use >4 hours/night on >70% of nights), pharmacologic treatment is indicated: 2, 5

Modafinil is the primary FDA-approved agent for residual sleepiness in OSA:

• Dosing: 200 mg once daily in the morning, can increase to 400 mg if needed 2
• Modafinil improves wakefulness on Maintenance of Wakefulness Test (MWT) and Clinical Global Impression of Change (CGI-C) scores 2
• Does not replace CPAP—patients must continue CPAP therapy 2
• Armodafinil is an alternative with similar efficacy 5

For elderly patients with cognitive impairment and excessive somnolence:

• Modafinil can be started at 100 mg once upon awakening, increased at weekly intervals as necessary 6
• Methylphenidate or dextroamphetamine 2.5-5 mg orally with breakfast is an alternative 6
• Monitor for hypertension, palpitations, arrhythmias, irritability, or behavioral changes 6
• Caffeine (last dose no later than 4:00 pm) can be used as adjunctive therapy 6

For Central Disorders of Hypersomnolence (Narcolepsy)

Modafinil 200-400 mg daily is FDA-approved for narcolepsy-associated excessive sleepiness:

• Demonstrated statistically significant improvements in MWT sleep latency and CGI-C scores in two 9-week trials 2
• Does not affect nighttime sleep architecture 2
• May be less effective than traditional stimulants (methylphenidate, amphetamines) for some narcoleptic patients 7

Critical Safety Warnings

Stop modafinil immediately and seek emergency care if:

• Skin rash, hives, mouth sores, blisters, or peeling skin develop 2
• Swelling of face, eyes, lips, tongue, or throat occurs 2
• Fever, shortness of breath, leg swelling, jaundice, or dark urine appear 2

Avoid benzodiazepines and zolpidem in elderly patients with cognitive impairment as they worsen cognitive performance and increase fall risk 6

Alcohol and opioids should be avoided or used with extreme caution as they can worsen OSA 1

When Pharmacologic Treatment is NOT Recommended

Pharmacologic agents are not supported as primary treatment for OSA (mirtazapine, xylometazoline, fluticasone, paroxetine, pantoprazole, acetazolamide, protriptyline all have insufficient evidence) 1

Sleep hygiene alone is no longer supported as single-component therapy for insomnia, though it remains a component of multicomponent treatments 1