American Academy of Sleep Medicine Recommendations for Sleep Maintenance Insomnia
For sleep maintenance insomnia specifically, the American Academy of Sleep Medicine recommends four pharmacological agents: suvorexant, doxepin, eszopiclone, zolpidem, and temazepam, with cognitive behavioral therapy for insomnia (CBT-I) remaining the preferred first-line treatment. 1, 2
Treatment Algorithm
First-Line: Non-Pharmacological Approach
- CBT-I should be initiated before pharmacotherapy in all patients with sleep maintenance insomnia, as it produces sustained benefits without tolerance or adverse effects 2, 3
- CBT-I includes sleep restriction, stimulus control techniques, cognitive restructuring of unhelpful sleep beliefs, and relaxation training 4, 3
- Between 70-80% of patients benefit from non-pharmacological interventions, with improvements sustained for at least 6 months 5
Second-Line: Pharmacological Options
Medications Specifically for Sleep Maintenance Insomnia
The AASM provides weak recommendations (meaning benefits outweigh harms but patient preference matters) for the following agents specifically targeting sleep maintenance insomnia:
Suvorexant is recommended for sleep maintenance insomnia through its unique mechanism of blocking orexin neuropeptides that promote wakefulness 1, 6
Doxepin is recommended for sleep maintenance insomnia through selective H1 receptor antagonism at low doses 1, 6
Medications for Both Sleep Onset AND Sleep Maintenance Insomnia
The following agents are recommended when patients have both sleep onset and maintenance difficulties:
Eszopiclone is recommended for both sleep onset and sleep maintenance insomnia 1, 2
- Dosing: 2-3 mg 6
Zolpidem is recommended for both sleep onset and sleep maintenance insomnia 1, 2
- All recommendations carry weak strength due to publication bias, small trial numbers, and data heterogeneity 1
Temazepam is recommended for both sleep onset and sleep maintenance insomnia, though benzodiazepines carry risks of cognitive impairment, tolerance, dependence, and falls 1, 6
- Dosing: 15 mg 6
Medications NOT Recommended
The AASM explicitly recommends against using the following agents for sleep maintenance insomnia:
- Trazodone should not be used for sleep maintenance insomnia 1, 2
- Tiagabine should not be used 1, 2
- Diphenhydramine and other antihistamines should not be used for chronic insomnia 1, 6
- Melatonin should not be used for sleep maintenance insomnia 1, 2
- Tryptophan should not be used 1, 2
- Valerian should not be used 1, 2
Critical Clinical Considerations
Monitoring and Follow-Up
- Follow patients every few weeks initially to assess effectiveness, side effects, and need for ongoing medication 6
- All pharmacological recommendations are rated as "WEAK" according to GRADE methodology, indicating that while benefits outweigh harms, many patients might reasonably choose not to use these treatments 2
Important Caveats
- Avoid combining multiple sedating agents without careful consideration, as this increases fall risk and cognitive impairment 6
- The weak recommendation strength reflects predictable GRADE downgrading due to pharmaceutical industry funding of most trials, publication bias risk, small trial numbers per agent, and data heterogeneity 1
- Pharmacotherapy should be supplemented with CBT-I when possible, as CBT-I remains the first-line treatment with the most favorable benefit-to-risk ratio 1, 2
- The ultimate treatment decision must consider specific treatment goals, comorbidities, prior treatment responses, availability, safety, patient preference, and cost 1
Special Populations
- In postpartum women with sleep maintenance insomnia, CBT-I is the preferred approach due to safety concerns with sedating medications during breastfeeding 4
- If pharmacotherapy is necessary postpartum, zolpidem may be considered with explicit FDA guidance to monitor infants for increased sleepiness, breathing difficulties, or limpness, and consider pumping and discarding breastmilk for 23 hours after administration 4