Is Benadryl Recommended for Sleep?
No, Benadryl (diphenhydramine) is not recommended for the treatment of insomnia due to lack of demonstrated efficacy and significant safety concerns, particularly anticholinergic effects and daytime impairment. 1
Guideline Recommendations Against Diphenhydramine
Multiple major sleep medicine societies explicitly recommend against using diphenhydramine for insomnia:
The American Academy of Sleep Medicine does not recommend over-the-counter antihistamine sleeping aids due to lack of demonstrated efficacy as well as safety concerns 1, 2
The VA/DOD Clinical Practice Guidelines include a "weak against" recommendation for diphenhydramine in chronic insomnia disorder 1
Evidence for efficacy and safety is very limited, with very few available studies from the past 10 years using contemporary study designs and outcomes 1
Why Diphenhydramine Should Be Avoided
Anticholinergic Side Effects
- Diphenhydramine causes serious anticholinergic effects including dry mouth and eyes, constipation, urinary retention, and increased risk for narrow-angle glaucoma 2
- These anticholinergic properties pose particular risks in older adults 1
Daytime Impairment and Safety Risks
- First-generation antihistamines like diphenhydramine cause significant sedative effects including drowsiness and performance impairment, even without subjective awareness 2
- Older adults are particularly susceptible to psychomotor impairment, with increased risk of falls and subdural hematomas 2
- The FDA label warns of marked drowsiness, need to avoid driving/operating machinery, and potential for excitability especially in children 3
Limited Efficacy Data
- A 2015 systematic review concluded that diphenhydramine and other commonly used OTC sleep aids "lack robust clinical evidence supporting efficacy and safety" 4
- While some older studies showed modest improvements, these effects were minimal and inconsistent 5, 6
What Should Be Used Instead
First-Line Treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) should be the initial treatment for chronic insomnia before considering any pharmacotherapy 1, 2, 7
When Pharmacotherapy Is Needed
If CBT-I alone is unsuccessful, the following medications are recommended:
First-line pharmacologic agents:
- Short/intermediate-acting benzodiazepine receptor agonists (zolpidem, eszopiclone) 1, 2, 7
- Ramelteon 1, 2
Second-line agents (preferred non-scheduled options):
- Low-dose doxepin (3-6 mg) - particularly effective for sleep maintenance insomnia with high-strength evidence 2, 7, 8
- Trazodone (typically 50 mg) 2, 7
- Mirtazapine - especially when comorbid depression exists 2, 7
Clinical Approach Algorithm
- Start with CBT-I as foundation of treatment 2, 7
- If pharmacotherapy needed, use shared decision-making to discuss benefits, harms, and costs 1
- Select first-line agents (benzodiazepine receptor agonists or ramelteon) for short-term use 1, 2
- Consider sedating antidepressants as second-line, especially with comorbid mood disorders 2, 7
- Start at lowest effective dose and use for shortest period possible 2, 7
- Reassess after 1-2 weeks and monitor for adverse effects 7
Special Considerations for Older Adults
- Extreme caution required in older adults due to increased sensitivity to adverse effects 2, 8
- Low-dose doxepin (3-6 mg) is the most appropriate medication for sleep maintenance insomnia in elderly patients 8
- Avoid benzodiazepines entirely in elderly due to risks of dependency, falls, cognitive impairment, and respiratory depression 8
Common Pitfalls to Avoid
- Do not recommend diphenhydramine simply because it is available over-the-counter - lack of prescription requirement does not indicate safety or efficacy 1, 2
- Long-term use of non-prescription treatments is not recommended - safety and efficacy in long-term treatment is unknown 1
- Do not rely on sleep hygiene education alone as treatment for chronic insomnia - it has insufficient evidence as stand-alone therapy 1