What is the recommended first-line treatment for insomnia?

First-Line Treatment for Insomnia

Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for all adults with chronic insomnia and should be initiated before any pharmacological intervention. 1, 2, 3

Why CBT-I is First-Line

CBT-I demonstrates superior long-term efficacy compared to medications, with sustained benefits lasting up to 2 years and minimal risk of adverse effects. 1, 3 The treatment addresses the underlying mechanisms maintaining insomnia rather than just suppressing symptoms. 2

Key components of effective CBT-I include:

• Sleep restriction therapy (limiting time in bed to match actual sleep time) 1, 3
• Stimulus control (using bedroom only for sleep, getting out of bed if unable to sleep) 1, 3
• Cognitive restructuring to address maladaptive thoughts about sleep 3
• Sleep hygiene education (though insufficient as monotherapy) 1, 2

CBT-I Delivery Options

CBT-I can be delivered through multiple effective formats: in-person individual therapy, group sessions, telephone-based programs, web-based modules, or self-help books. 1, 2 This flexibility addresses common barriers including cost, geographic limitations, and provider availability. 1

When to Consider Pharmacotherapy

Medications should only be considered as second-line when:

• Patients are unable to participate in CBT-I 3
• Symptoms persist despite adequate CBT-I trial 3
• As a temporary adjunct to CBT-I (not replacement) 2, 3

First-Line Pharmacological Options (When Necessary)

If pharmacotherapy is required, the American Academy of Sleep Medicine recommends short-intermediate acting benzodiazepine receptor agonists (BzRAs) or ramelteon as first-line medications. 2

For sleep onset insomnia:

• Zaleplon 10 mg 2
• Zolpidem 10 mg (5 mg in elderly) 2
• Ramelteon 8 mg 2

For sleep maintenance insomnia:

• Eszopiclone 2-3 mg 2
• Zolpidem 10 mg 2
• Temazepam 15 mg 2

For both onset and maintenance:

• Eszopiclone, zolpidem, or temazepam 2

Second-Line Pharmacological Options

• Low-dose doxepin 3-6 mg for sleep maintenance 2
• Suvorexant (orexin receptor antagonist) for sleep maintenance 2
• Sedating antidepressants when comorbid depression/anxiety is present 2

Critical Medications to Avoid

Do NOT use as first-line:

• Over-the-counter antihistamines (diphenhydramine) due to lack of efficacy data, daytime sedation, and delirium risk especially in older patients 1, 2, 3
• Antipsychotics due to problematic metabolic side effects 1, 2
• Long-acting benzodiazepines (diazepam, clonazepam, lorazepam) due to accumulation and increased risks 1, 2
• Herbal supplements (valerian) and melatonin due to insufficient evidence of efficacy 1, 2
• Trazodone is not recommended by the American Academy of Sleep Medicine 2

Treatment Algorithm

Step 1: Initiate CBT-I as primary intervention for all patients 1, 2, 3

Step 2: If CBT-I insufficient or unavailable after adequate trial, add short-term pharmacotherapy while continuing behavioral interventions 2, 3

Step 3: Select medication based on symptom pattern:

• Sleep onset difficulty → zaleplon, ramelteon, or zolpidem 2
• Sleep maintenance → eszopiclone, temazepam, doxepin, or suvorexant 2

Step 4: Use lowest effective dose for shortest period possible (typically <4 weeks for acute insomnia) 2

Step 5: If first-line medication fails, try alternative BzRA before moving to second-line agents 2

Critical Safety Considerations

All hypnotics carry significant risks:

• Daytime impairment and cognitive changes 2
• Complex sleep behaviors (sleep-driving, sleep-walking) 2
• Falls and fractures, particularly in elderly patients 2
• Dependence and withdrawal with prolonged use 2

For elderly patients:

• Use lower doses (zolpidem 5 mg maximum) 2
• Avoid benzodiazepines due to increased fall risk and cognitive impairment 2, 4
• Consider trazodone 50 mg or orexin receptor antagonists in dementia patients 4

Common Pitfalls to Avoid

• Starting with medications before attempting CBT-I 1, 3
• Using sleep hygiene education alone without other CBT-I components 1, 2
• Prescribing over-the-counter antihistamines or herbal supplements 1, 2, 3
• Continuing pharmacotherapy long-term without periodic reassessment 2, 3
• Failing to supplement medication with behavioral interventions 2
• Using sedating agents without matching them to specific sleep complaints (onset vs. maintenance) 2

Monitoring Requirements

Regular follow-up is essential to assess effectiveness, side effects, and need for medication adjustments. 2 If insomnia persists beyond 7-10 days of treatment, evaluate for underlying sleep disorders such as sleep apnea, restless legs syndrome, or circadian rhythm disorders. 2