Restoril (Temazepam) for Insomnia in a Patient with Old TBI
Direct Recommendation
Temazepam is a reasonable option for this patient with old TBI who has failed multiple other sleep medications, but it should be used cautiously at the lowest effective dose (7.5-15 mg) with close monitoring for cognitive effects and fall risk. 1, 2
Evidence-Based Rationale
Why Temazepam May Be Appropriate Here
The American Academy of Sleep Medicine guidelines recommend temazepam (15 mg) as a first-line pharmacological treatment for insomnia, demonstrating efficacy for subjective sleep latency, total sleep time, and sleep quality with minimal adverse effects in controlled trials 1
This patient has already failed the recommended treatment hierarchy: they've tried sedating antidepressants (mirtazapine, trazodone), atypical antipsychotics (quetiapine), and non-benzodiazepine hypnotics (eszopiclone/Lunesta) 3
Temazepam has a favorable pharmacokinetic profile with intermediate half-life (5-11 hours), no active metabolites, and minimal next-day residual effects at appropriate doses, making it safer than longer-acting benzodiazepines 1, 2, 4
Critical Safety Considerations in TBI
GABA agonists (including benzodiazepines like temazepam) raise concerns about neuroplasticity and cognitive recovery in TBI patients, though most evidence addresses acute TBI rather than remote injury 5
The cognitive impairment risk is highest when plasma levels peak (1.2-1.6 hours post-dose), but residual cognitive effects are less pronounced with temazepam compared to longer-acting benzodiazepines 5, 2
Since this is an "old" TBI (remote injury), the neuroplasticity concerns are substantially less relevant than in acute recovery phases where neural reorganization is actively occurring 5
Dosing Strategy for This Patient
Start with 7.5 mg, not the standard 15 mg dose, given the TBI history and need to minimize cognitive effects 1, 2
Temazepam 7.5 mg showed efficacy in elderly patients (who also have increased vulnerability to cognitive effects), suggesting this lower dose can be effective while reducing risk 1, 6
The dose can be titrated to 15 mg if 7.5 mg is insufficient, but avoid the 30 mg dose which shows more morning cognitive impairment 1, 6
Important Warnings from FDA Labeling
Physical dependence develops with continued use; discontinuation requires gradual taper to avoid potentially life-threatening withdrawal seizures 2
Complex sleep behaviors (sleep-driving, sleep-eating) can occur, and temazepam should be discontinued immediately if these emerge 2
Risk of falls is elevated, particularly concerning given TBI patients may already have balance or coordination issues 2
Avoid concurrent use with opioids or other CNS depressants due to risk of fatal respiratory depression 2
Monitoring Requirements
Assess for next-day cognitive impairment, particularly memory and psychomotor function, as TBI patients may be more vulnerable to these effects 5, 2
Evaluate fall risk at each visit, especially if the patient has any residual motor deficits from TBI 2, 6
Plan for time-limited use (ideally 2-4 weeks) rather than indefinite treatment, with regular reassessment of continued need 2, 1
Monitor for tolerance development, though studies show temazepam maintains efficacy for at least 2 weeks without significant tolerance 2, 7
Common Pitfalls to Avoid
Do not assume benzodiazepines are absolutely contraindicated in all TBI patients—the evidence primarily addresses acute TBI and neuroplasticity during active recovery, not remote injuries 5
Do not start at 30 mg dose, as this increases risk of morning cognitive impairment and adverse effects without proportional benefit 1, 6
Do not continue indefinitely without attempting dose reduction or discontinuation, as dependence risk increases with duration of use 2
Do not overlook non-pharmacological interventions—cognitive behavioral therapy for insomnia (CBT-I) combined with temazepam reduces medication requirements and adverse effects 6
Why Other Failed Medications Were Appropriate to Try First
Trazodone and mirtazapine are recommended as second/third-line agents with better safety profiles than benzodiazepines, so trying these first was appropriate 3
Quetiapine (Seroquel) is explicitly not recommended for primary insomnia due to weak evidence and significant metabolic/neurological risks, though it's sometimes used off-label 3
Eszopiclone (Lunesta) is a first-line agent with less dependence potential than benzodiazepines, so this was an appropriate earlier trial 3
The Bottom Line
Given the treatment-refractory nature of this patient's insomnia and the remote (not acute) TBI, temazepam 7.5-15 mg represents a reasonable next step, balancing efficacy against the theoretical cognitive risks that are most relevant in acute TBI recovery. 1, 5 The key is starting low, monitoring closely, and planning for eventual discontinuation rather than indefinite use. 2, 6