What is the best medication for insomnia?

Best Medication for Insomnia

For chronic insomnia requiring pharmacotherapy, short-intermediate acting benzodiazepine receptor agonists (BzRAs) are first-line, with eszopiclone 2-3 mg, zolpidem 10 mg (5 mg in elderly), or ramelteon 8 mg as the preferred initial agents, selected based on whether the primary complaint is sleep onset versus sleep maintenance. 1

Treatment Algorithm

Step 1: Confirm Pharmacotherapy is Appropriate

• Cognitive Behavioral Therapy for Insomnia (CBT-I) should precede any medication trial, as it demonstrates superior long-term efficacy and minimal adverse effects compared to pharmacotherapy 1, 2
• Pharmacotherapy is appropriate when CBT-I is insufficient, unavailable, or when rapid symptom control is needed 1
• Short-term use (typically less than 4 weeks for acute insomnia) is recommended, using the lowest effective dose 1

Step 2: Identify Sleep Pattern

For Sleep Onset Insomnia (difficulty falling asleep):

• Zaleplon 10 mg - ultra-short acting, ideal for pure sleep onset issues 1, 2
• Zolpidem 10 mg (5 mg elderly) - effective for both onset and maintenance 1, 2, 3
• Ramelteon 8 mg - melatonin receptor agonist, lower abuse potential 1, 2
• Triazolam 0.25 mg - not first-line due to rebound anxiety risk 1

For Sleep Maintenance Insomnia (difficulty staying asleep):

• Eszopiclone 2-3 mg - FDA-approved for both onset and maintenance with no short-term restrictions, unique in demonstrating 6-month efficacy 1, 2, 4, 5
• Zolpidem 10 mg - effective for maintenance as well as onset 1, 2, 3
• Temazepam 15 mg (7.5 mg elderly) - intermediate-acting benzodiazepine 1, 2
• Doxepin 3-6 mg - second-line option, particularly for maintenance 1, 2
• Suvorexant - orexin receptor antagonist, second-line for maintenance 1

Step 3: Consider Patient-Specific Factors

Elderly Patients:

• Use lower doses: zolpidem 5 mg, temazepam 7.5 mg, or eszopiclone 1-2 mg 1, 2, 3, 4
• Eszopiclone 2 mg uniquely improves next-day functioning and reduces daytime napping in elderly patients 6
• Avoid long-acting benzodiazepines due to increased fall risk and cognitive impairment 1

Comorbid Depression/Anxiety:

• Consider sedating antidepressants as first-line alternatives to BzRAs 1
• Low-dose doxepin 3-6 mg, amitriptyline, or mirtazapine may be appropriate 1
• Lorazepam is second or third-line when first-line agents fail and anxiety is prominent 1

Long-term Treatment:

• Eszopiclone is the only agent evaluated and approved for long-term use (up to 6 months) without short-term restrictions 1, 4, 5, 6
• No clinically significant tolerance, rebound insomnia, or dependence demonstrated in trials up to 12 months 6
• All other hypnotics should be prescribed for short periods with periodic reassessment 1

Critical Safety Considerations

Next-Day Impairment:

• Eszopiclone 3 mg causes psychomotor and memory impairment that persists up to 11.5 hours post-dose, even when patients don't perceive sedation 4
• Zolpidem shows small but statistically significant decreases in performance on cognitive testing 3
• Anterograde amnesia can occur, particularly with doses >10 mg 3

Monitoring Requirements:

• Follow patients every few weeks initially to assess effectiveness and side effects 1, 2
• Supplement pharmacotherapy with behavioral and cognitive therapies whenever possible 1, 2
• Taper medications when conditions allow to prevent discontinuation symptoms 1

Agents to Avoid

Not Recommended:

• Trazodone - despite common clinical use, not recommended by AASM 1, 2
• Over-the-counter antihistamines (diphenhydramine) - lack efficacy data, cause daytime sedation and delirium risk, especially in elderly 1, 2
• Melatonin, valerian, L-tryptophan - insufficient evidence of efficacy 1, 2
• Tiagabine - not recommended for insomnia 1
• Barbiturates and chloral hydrate - not recommended 1, 2
• Antipsychotics - should not be first-line due to metabolic side effects 1

Common Pitfalls

• Using sedating agents without matching them to specific sleep onset versus maintenance patterns 1
• Failing to assess drug interactions and contraindications before prescribing 1
• Continuing long-term pharmacotherapy without periodic reassessment and attempts at discontinuation 1, 2
• Prescribing over-the-counter sleep aids with limited safety and efficacy data 1
• Neglecting to implement CBT-I techniques alongside medication 1