What medication is recommended for patients with insomnia?

Medication for Insomnia

For patients with chronic insomnia, short-intermediate acting benzodiazepine receptor agonists (BzRAs)—specifically zolpidem 10mg, eszopiclone 2-3mg, zaleplon 10mg, or temazepam 15mg—or ramelteon 8mg are recommended as first-line pharmacological agents, with the choice determined by whether the primary complaint is sleep onset versus sleep maintenance difficulty. 1, 2

First-Line Pharmacological Options

The American Academy of Sleep Medicine provides clear guidance on medication selection based on sleep pattern 1, 2:

For Sleep Onset Insomnia (Difficulty Falling Asleep):

• Zaleplon 10mg - shortest acting option, specifically for sleep initiation 1, 2
• Ramelteon 8mg - melatonin receptor agonist with minimal cognitive risk and no GABA receptor effects, FDA-approved for sleep onset difficulty 1, 3
• Zolpidem 10mg (5mg in elderly) - effective for both onset and maintenance 1, 2, 4

For Sleep Maintenance Insomnia (Difficulty Staying Asleep):

• Eszopiclone 2-3mg - demonstrated efficacy for both onset and maintenance, with long-term safety data up to 12 months 1, 2, 5
• Zolpidem 10mg - superior to placebo on sleep efficiency measures 1, 4
• Temazepam 15mg - traditional benzodiazepine option, though should be avoided in older patients due to cognitive impairment and fall risk 6, 1
• Suvorexant 10-20mg - orexin receptor antagonist specifically for maintenance insomnia 6, 2
• Doxepin 3-6mg - low-dose formulation for middle-of-the-night awakenings 6, 1, 2

For Both Onset and Maintenance:

• Eszopiclone 2-3mg - most versatile option with demonstrated long-term efficacy 1, 2, 5
• Zolpidem 10mg (5mg in elderly) - FDA-approved for both components 1, 4

Second-Line Options

If initial BzRAs or ramelteon fail, try an alternate agent from the same class before moving to other categories 7, 1.

Sedating antidepressants become appropriate when treating comorbid depression or anxiety 7, 1, 2:

• Trazodone, amitriptyline, doxepin (higher doses), and mirtazapine 7, 1
• Important caveat: Trazodone at 50mg is specifically recommended AGAINST for sleep maintenance insomnia by the American Academy of Sleep Medicine 6

Medications to Explicitly Avoid

The American Academy of Sleep Medicine provides strong recommendations against several commonly used agents 7, 1, 2:

• Over-the-counter antihistamines (diphenhydramine) - lack of efficacy data, anticholinergic effects, daytime sedation, and delirium risk especially in elderly 7, 1, 2
• Melatonin 2mg - insufficient evidence for efficacy 6, 1
• Valerian and herbal supplements - lack efficacy and safety data 7, 1, 2
• Barbiturates and chloral hydrate - outdated with unacceptable safety profiles 7, 2
• Tiagabine - insufficient benefit demonstrated 7, 2

Critical Safety Considerations and Prescribing Principles

All hypnotics should be prescribed at the lowest effective dose for the shortest necessary duration 1, 2. The American Academy of Sleep Medicine emphasizes several key safety points:

• Cognitive risks: Both benzodiazepines and Z-drugs (zolpidem, eszopiclone, zaleplon) act on GABA receptors and carry risks of amnesia, cognitive impairment, and potential contribution to dementia with long-term use 1, 8
• Zolpidem-specific concerns: Increased fall risk (OR 4.28), hip fractures (RR 1.92), complex sleep behaviors (sleepwalking, sleep-driving), and increased suicide risk (OR 2.08) 8
• Follow-up schedule: Monitor every few weeks initially to assess effectiveness, side effects, and ongoing need 7, 1
• Dosing strategies: Consider intermittent dosing (three nights per week) or as-needed use to reduce tolerance and dependence 7, 1

Required Patient Education

All pharmacological treatment must include education about 7, 1:

• Treatment goals and realistic expectations
• Safety concerns and potential side effects
• Drug interactions
• Availability of cognitive-behavioral treatments (CBT-I)
• Risk of dosage escalation
• Potential for rebound insomnia upon discontinuation

Long-Term Management

Medication tapering should be attempted when conditions allow, with CBT-I facilitating successful discontinuation 7, 1. Long-term use may be indicated for severe/refractory insomnia or chronic comorbid illness, but requires consistent follow-up and ongoing assessment 7, 1.

Common Pitfalls to Avoid

• Using sedating agents without matching them to specific sleep complaints (onset vs. maintenance) 2
• Prescribing long-term without periodic reassessment and attempts at tapering 1, 2
• Failing to implement or offer CBT-I alongside medication 1, 2
• Using higher doses than necessary (e.g., zolpidem 16mg confers no additional benefit over 10mg but increases side effects) 3
• Prescribing temazepam to elderly patients given fall and cognitive risks 6, 1