Medication for Insomnia in Adolescents
Melatonin is the recommended first-line pharmacologic treatment for insomnia in adolescents, starting at 3-5 mg administered 30-60 minutes before bedtime, with dose titration up to 6 mg if needed after 2 weeks. 1, 2, 3
Initial Treatment Approach
Behavioral interventions should be attempted first, including consistent bedtime routines, fixed sleep/wake times, and addressing any underlying anxiety or psychiatric comorbidities that directly contribute to sleep difficulties. 2 However, when behavioral approaches are unsuccessful after 2-4 weeks, melatonin becomes the appropriate next step. 1, 2
Melatonin Dosing Protocol
Starting Dose
- Adolescents (typically 13-20 years): Begin with 3-5 mg administered 30-60 minutes before desired bedtime 3, 4
- For adolescents with neurodevelopmental disorders (autism, ADHD): Start at 1 mg, given 30-40 minutes before bedtime 1, 2
Dose Escalation
- If ineffective after 2 weeks, increase by 1 mg every 2 weeks up to a maximum of 6 mg 1, 2
- Weight-based approach for those with psychiatric comorbidities: 3 mg if <40 kg, 5 mg if >40 kg 5
Expected Benefits
- Sleep latency reduction of 22-60 minutes 6
- Total sleep time increase of approximately 18-37 minutes 4, 6
- Improvements in bedtime resistance and sleep anxiety 1
Safety Profile
Melatonin demonstrates excellent short-term safety in adolescents with only mild, self-limiting adverse effects. 3, 4, 6
Common side effects include:
- Morning sleepiness (monitor especially in school-aged children) 1, 5
- Headache (0.74% incidence) 5
- Loose stools (~1% of patients) 1
- Dizziness 5
Long-term safety data up to 24 months shows:
- No serious adverse events 1, 6
- No effects on pubertal development or growth 5, 6
- No evidence of dependence or withdrawal 3, 6
Duration of Treatment
- Maximum recommended duration for chronic insomnia: 3-4 months 5
- For circadian rhythm disorders (delayed sleep-wake phase disorder), longer-term use may be appropriate 5
- Reassess treatment need every 3-6 months and attempt periodic dose reduction or discontinuation, preferably during summer holidays 5, 6
Critical Pitfalls to Avoid
Product quality concerns: Melatonin is regulated as a dietary supplement in the US, raising significant concerns about purity and reliability of stated doses. 5 Choose United States Pharmacopeial Convention Verified formulations for reliable dosing. 5
Timing is crucial: Administer melatonin 30-60 minutes before bedtime for sleep onset insomnia, or 1.5-2 hours before habitual bedtime for circadian rhythm disorders. 5, 6
Monitor for treatment-emergent daytime sleepiness, which can impair school performance and requires dose adjustment. 2
Drug interactions: Use with caution in patients taking warfarin or those with epilepsy. 5
Alternative Medications (Second-Line)
When melatonin fails or is contraindicated, trazodone is the most commonly used second-choice treatment by pediatric psychiatrists (57% of respondents). 7 However, the American Academy of Sleep Medicine guidelines for adults suggest against trazodone use due to limited evidence. 7
Medications to avoid in adolescents:
- Benzodiazepines (lorazepam, alprazolam): Risk of respiratory depression, ataxia, excessive sedation, memory impairment, and paradoxical disinhibition 7
- Second-generation antipsychotics (quetiapine): Significant metabolic side effects including metabolic syndrome; should not be prescribed for sleep disturbances alone 7
- Antihistamines (diphenhydramine): Not recommended by adult guidelines, limited pediatric data 7
Follow-Up Protocol
- Schedule follow-up within 2-4 weeks after initiating melatonin 2
- Use sleep diaries to objectively track sleep onset, duration, and night wakings 2
- Expect improvement within 4 weeks; if no benefit is seen, reassess diagnosis and consider alternative approaches 2
- If treatment is successful, continue for 3-4 months maximum, then attempt gradual discontinuation 5