What is the best herbal medicine for insomnia?

Herbal Medicines for Insomnia: Evidence-Based Recommendations

Based on the highest quality clinical practice guidelines, clinicians should NOT use herbal medicines for the treatment of chronic insomnia, as they lack demonstrated efficacy and carry potential safety concerns. 1

Primary Recommendations Against Herbal Treatments

Valerian

• The American Academy of Sleep Medicine (AASM) recommends AGAINST using valerian for sleep onset or sleep maintenance insomnia (weak recommendation based on variable quality evidence). 1
• While valerian showed marginal improvements in polysomnography sleep latency (9.29 minutes reduction), this fell below clinical significance thresholds, and subjective sleep latency actually worsened. 1
• The most recent 2024 umbrella review confirms no evidence of efficacy for insomnia treatment, despite valerian's widespread use. 2
• Multiple systematic reviews consistently demonstrate that valerian does not produce clinically meaningful improvements in objective sleep measures. 2, 3

L-Tryptophan

• The AASM recommends AGAINST using tryptophan for sleep onset or sleep maintenance insomnia (weak recommendation based on high-quality evidence for 250 mg doses). 1
• Studies showed modest declines in total sleep time that were not clinically significant, with potential harms outweighing benefits. 1

Kava

• The FDA recommends AGAINST using kava for insomnia due to lack of proven efficacy and significant risk of acute fatal liver toxicity. 4
• Studies demonstrate no benefit compared to placebo for chronic insomnia disorder. 4
• Kava carries serious risks including hepatotoxicity, decreased renal blood flow, and multiple cytochrome P450 enzyme interactions. 4

Melatonin and Other Agents

• The American College of Physicians found insufficient evidence to determine efficacy of melatonin for chronic insomnia. 1
• Over-the-counter antihistamines and herbal substances were not recommended due to relative lack of efficacy, safety data, and potential for rebound insomnia. 1

What Should Be Used Instead

First-Line Treatment

• Cognitive Behavioral Therapy for Insomnia (CBT-I) is the recommended first-line treatment for chronic insomnia (strong recommendation, moderate-quality evidence). 1
• The AASM strongly recommends CBT-I as standard of care before considering any pharmacological interventions. 1, 4

Second-Line Pharmacological Options (If CBT-I Insufficient)

• Short/intermediate-acting benzodiazepine receptor agonists (zaleplon, zolpidem, eszopiclone) or ramelteon should be considered only after CBT-I failure, using shared decision-making. 1
• Pharmacotherapy should be short-term (4-5 weeks) and at the lowest effective dose. 1

Critical Clinical Pitfalls

Common mistakes to avoid:

• Prescribing herbal remedies based on patient preference or perceived "natural" safety without discussing lack of efficacy evidence. 1
• Failing to warn patients about kava's hepatotoxicity risk and drug interactions via cytochrome P450 inhibition. 4
• Not recognizing that subjective improvements in sleep quality with valerian do not translate to objective or clinically meaningful benefits. 2, 3
• Overlooking that most herbal insomnia studies have significant methodological problems and publication bias. 1, 5

Special Populations

In cancer patients:

• Due to relative lack of efficacy and safety data, valerian and melatonin are not recommended for chronic insomnia treatment. 1
• A phase III trial in cancer patients showed no effect of valerian (450 mg) on sleep quality. 1

Perioperative considerations:

• Kava must be discontinued at least 2 weeks before surgery due to CNS depression and cyclooxygenase inhibition risks. 4