What is the best medication for insomnia?

Best Medication for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the first-line treatment before any medication is considered, but when pharmacotherapy is necessary, non-benzodiazepine receptor agonists (zolpidem 10mg or eszopiclone 2-3mg) are the preferred first-line medications for most adults with insomnia. 1, 2

Treatment Algorithm

Step 1: Non-Pharmacological Treatment First

• CBT-I must be initiated as the initial treatment for all adults with chronic insomnia due to superior long-term efficacy compared to medications and minimal risk of adverse effects 1, 2
• CBT-I includes stimulus control therapy, sleep restriction therapy, relaxation techniques, and cognitive therapy components 1
• Brief behavioral therapy may be appropriate when resources are limited, delivered over 2-4 sessions 1

Step 2: First-Line Pharmacotherapy (When CBT-I Fails or Is Insufficient)

For Sleep Onset Insomnia:

• Zolpidem 10mg (5mg in elderly) - demonstrated superiority over placebo for reducing sleep latency in both transient and chronic insomnia 2, 3
• Zaleplon 10mg - very short half-life with minimal residual sedation, ideal for sleep onset problems 2
• Ramelteon 8mg - particularly suitable for patients with substance use history due to no dependence potential 1, 2

For Sleep Maintenance Insomnia:

• Eszopiclone 2-3mg - superior efficacy for both sleep onset and maintenance, with evidence supporting use up to 6 months 2, 4
• Zolpidem 10mg (5mg in elderly) - effective for both onset and maintenance 2, 3
• Low-dose doxepin 3-6mg - particularly effective for sleep maintenance with minimal side effects 1, 2
• Temazepam 15mg - benzodiazepine option for both onset and maintenance 2

Step 3: Second-Line Options (When First-Line Fails)

• Suvorexant (orexin receptor antagonist) - for sleep maintenance insomnia 1, 2
• Sedating antidepressants (trazodone, mirtazapine, doxepin) - especially when comorbid depression/anxiety exists 1, 2
• Alternative benzodiazepine receptor agonists if initial agent unsuccessful 2

Critical Prescribing Principles

• Use the lowest effective dose for the shortest duration possible - FDA approval is for short-term use only (4-5 weeks) 1
• Continue behavioral techniques even when using medications - pharmacotherapy should supplement, not replace, behavioral interventions 1, 2
• Monitor regularly for treatment response, adverse effects, and potential misuse 1
• Taper medications when conditions allow to prevent discontinuation symptoms 1

Medications to Avoid

• Over-the-counter antihistamines (diphenhydramine) - not recommended due to lack of efficacy data, safety concerns, and problematic side effects like daytime sedation and delirium, especially in elderly 1, 2
• Antipsychotics (quetiapine, olanzapine) - not recommended as first-line due to metabolic side effects and weak supporting evidence 1, 2
• Trazodone - specifically not recommended by the American Academy of Sleep Medicine for sleep onset or maintenance insomnia 2
• Long-acting benzodiazepines (lorazepam) - carry increased risks without clear benefit, including dependence, cognitive impairment, falls, and daytime sedation 2
• Herbal supplements (valerian) and melatonin supplements - insufficient evidence of efficacy 2
• Barbiturates and chloral hydrate - not recommended 2

Important Safety Warnings

• Next-day impairment is a significant concern - FDA labels warn of daytime impairment, "sleep driving," and behavioral abnormalities 1
• Zolpidem 3mg causes objectively measured psychomotor and memory impairment that persists up to 11.5 hours after dosing, even when patients don't subjectively perceive impairment 4
• Eszopiclone 3mg causes next-morning psychomotor and memory impairment most severe at 7.5 hours but still present at 11.5 hours 4
• Long-term risks include potential associations with dementia, injury, and fractures 1
• Elderly patients require dose reduction (zolpidem 5mg, eszopiclone 1-2mg) due to increased risk of falls and cognitive impairment 2, 3

Common Pitfalls to Avoid

• Starting with medication before attempting CBT-I 1, 2
• Using sedating agents without considering their specific effects on sleep onset versus maintenance 2
• Failing to consider drug interactions and contraindications 2
• Continuing pharmacotherapy long-term without periodic reassessment 1, 2
• Prescribing higher doses than necessary or for longer than 4-5 weeks without reassessment 1