What can I do to manage my insomnia?

Managing Your Insomnia

Start with Cognitive Behavioral Therapy for Insomnia (CBT-I) immediately—this is the gold standard first-line treatment for chronic insomnia and is more effective and durable than medications. 1, 2

Why CBT-I Should Be Your Foundation

CBT-I is recommended as the standard treatment by the American College of Physicians and the American Academy of Sleep Medicine because it addresses the root causes of insomnia rather than just masking symptoms. 1, 2 Unlike medications, the benefits of CBT-I persist long-term—studies show sustained improvement for up to 2 years after treatment. 1

Core Components of CBT-I You Should Implement

Sleep Restriction Therapy

• Track your actual sleep time using a sleep log for 1-2 weeks, then limit your time in bed to match only your actual sleep duration. 1, 2 For example, if you're spending 8.5 hours in bed but only sleeping 6 hours, restrict your time in bed to 6 hours initially. 1
• This creates sleep pressure and consolidates your sleep, making it more efficient. 2
• Gradually increase time in bed by 15-30 minutes weekly once you achieve >85% sleep efficiency. 2

Stimulus Control Therapy

• Go to bed only when genuinely sleepy, not just tired. 1, 2
• If you cannot fall asleep within 20 minutes, get out of bed and do a quiet, non-stimulating activity in dim light until sleepy. 1, 2
• Use your bed only for sleep and sex—no TV, phone scrolling, or work. 1, 2
• Maintain a consistent wake time every day, regardless of how much you slept. 2
• Avoid daytime napping. 1, 2

Sleep Hygiene Modifications

Address these specific behaviors that impair sleep: 1

• Eliminate all caffeine after noon (not just coffee—also tea, soda, energy drinks, and medications containing caffeine). 1
• Avoid alcohol in the evening—while it may help you fall asleep initially, it fragments sleep later in the night. 1
• Stop smoking in the evening or quit entirely, as nicotine is a stimulant. 1
• Avoid late evening exercise—finish vigorous activity at least 3-4 hours before bed. 1
• Keep your bedroom dark, cool (around 65-68°F), and quiet. 1
• Avoid heavy meals close to bedtime. 1
• Stop clock-watching—turn clocks away from view to reduce anxiety about time passing. 1

Cognitive Therapy

• Address distorted beliefs about sleep, such as "I must get 8 hours or I'll be dysfunctional" or catastrophizing about the consequences of poor sleep. 1, 2
• Work on reducing anxiety and anticipation about poor sleep. 1

Relaxation Techniques

• Practice progressive muscle relaxation, deep breathing exercises, or guided imagery before bed. 1, 2

When to Consider Medication

Only add pharmacological therapy if CBT-I alone is insufficient after 2-4 weeks of consistent implementation. 2, 3 Medications should always be combined with ongoing CBT-I, never used as monotherapy. 2

First-Line Medication Options (if needed):

• Short/intermediate-acting benzodiazepine receptor agonists (BzRAs): zolpidem, eszopiclone, zaleplon, or temazepam. 1, 4
• Ramelteon (melatonin receptor agonist): particularly useful if you prefer a non-controlled substance or have substance use history. 1, 3

Important Medication Warnings:

• Zolpidem and other BzRAs carry serious risks including complex sleep behaviors (sleep-walking, sleep-driving, eating while asleep) that can result in serious injury or death. 4
• Take sleep medications only when you can dedicate a full 7-8 hours to sleep to avoid next-day impairment and dangerous activities like driving. 4
• Never combine sleep medications with alcohol. 4
• Avoid over-the-counter antihistamines (like diphenhydramine/Benadryl)—they cause anticholinergic side effects, daytime sedation, and tolerance, with limited evidence for efficacy. 2, 5

Second-Line Options (if first-line fails):

• Low-dose sedating antidepressants: trazodone, doxepin, or mirtazapine. 3, 5

Critical Pitfalls to Avoid

• Never use medications without concurrent behavioral therapy—this leads to dependence without addressing underlying sleep architecture problems. 2
• Screen for underlying causes before assuming primary insomnia: sleep apnea, restless legs syndrome, medication side effects, chronic pain, depression, or anxiety disorders. 2, 4
• Avoid long-term benzodiazepine use due to risks of dependence, tolerance, cognitive impairment, and falls (especially in older adults). 2
• Don't expect sleep hygiene alone to cure chronic insomnia—it must be combined with other CBT-I components. 1, 2

Follow-Up and Monitoring

• Reassess every 2-4 weeks initially to evaluate treatment effectiveness. 2, 3
• If insomnia doesn't improve after 7-10 days of treatment, this may indicate an underlying psychiatric or medical condition requiring further evaluation. 4
• Attempt medication tapering after 4-8 weeks when sleep consolidates, facilitated by ongoing CBT-I. 2, 3
• Consider referral to a sleep medicine specialist if insomnia persists despite these interventions. 6, 7