Insomnia

Start here to understand insomnia, why it happens, and what evidence-backed treatments look like.

Use the medication roadmap to compare options and print handouts when you’re ready to plan treatment with a clinician.

Understanding insomnia

Insomnia is persistent trouble falling asleep, staying asleep, or waking too early with daytime impairment.

Insomnia can be short-term (days to weeks) or chronic (≥3 nights/week for ≥3 months).
Daytime effects can include fatigue, poor concentration, irritability, and increased accident risk.
Many people experience insomnia during stress, illness, mood changes, or medication/substance shifts.

If you feel unsafe or in crisis, use the crisis banner (988 in the U.S.) or seek emergency care.

Common contributors and comorbidities

A good plan starts with identifying the drivers of poor sleep.

Mood and anxiety conditions, pain syndromes, and substance use can all worsen sleep quality.
Sleep apnea, restless legs syndrome, circadian rhythm disorders, and stimulant use may mimic insomnia.
Caffeine, alcohol, nicotine, and late-day screen time can reduce sleep depth and continuity.

If loud snoring, witnessed apneas, or excessive daytime sleepiness are present, ask about sleep apnea evaluation.

Evaluation and next steps

Work with a clinician to rule out medical and medication causes before escalating to hypnotics.

Review current medications (including antidepressants, stimulants, steroids) and timing of doses.
Track sleep patterns with a simple sleep diary for 1–2 weeks.
Consider labs and screening when clinically indicated (thyroid disease, iron deficiency, mood disorders).

First-line: behavioral and sleep-focused therapy

For chronic insomnia, CBT-I is usually first-line because it treats the underlying sleep system rather than only symptoms.

Keep a consistent wake time, even on weekends.
Use the bed for sleep (and sex) only; get out of bed if you are awake for long stretches.
Limit late-day caffeine and alcohol; keep the sleep environment dark, cool, and quiet.
If insomnia is linked to anxiety, combine CBT-I with anxiety-focused therapy for better durability.

Behavioral plans can feel counterintuitive at first; benefits typically build over weeks.

Medication options (when needed)

Medications can help in targeted situations, but risks differ by class and by patient factors (age, fall risk, substance use, respiratory disease).

Ramelteon — melatonin receptor agonist; useful for sleep-onset insomnia and minimal abuse potential.
Melatonin — OTC supplement; modest evidence and variable product quality; best fit is sleep-onset/circadian complaints.
Daridorexant, lemborexant, suvorexant — DORAs; can help with sleep onset and maintenance.
Doxepin (low dose) — maintenance-focused option; watch anticholinergic burden at higher antidepressant doses.
Zolpidem, eszopiclone, zaleplon — “Z-drugs”; short-term use, next-day impairment, and rare complex sleep behaviors are key counseling points.
Temazepam, estazolam, quazepam, and flurazepam are benzodiazepine hypnotics that can help short-term but carry dependence and withdrawal risk.
Sedating antidepressants (e.g., trazodone) are commonly used off-label; discuss evidence strength and daytime sedation.
OTC antihistamine sleep aids (diphenhydramine, doxylamine) are sedating but anticholinergic; avoid chronic use and avoid in older adults when possible.

Avoid combining sedatives with alcohol or other CNS depressants unless explicitly directed.

Medication roadmap for teams

Use these compare presets to quickly line up options and share a plan.

Compare DORAs for sleep-onset vs maintenance positioning.
Compare OTC sleep aids for sleep-onset positioning and anticholinergic burden.
Compare Z-drugs and benzos for onset vs duration and next-day sedation risk.
Compare benzodiazepine hypnotics for carryover impairment risk and taper planning.
Compare off-label sedating options when insomnia overlaps anxiety (verify indication + risks).
Open the Evidence Library and filter by type/year to refresh guideline links and newer trials.

Use the Share button in Compare to save a clinic-ready link.

Monitoring and safety pearls

Match the treatment to the risk profile and revisit regularly.

Counsel on next-day impairment (driving, falls), especially in older adults.
Screen for sleep apnea and respiratory disease before long-term sedative use.
Discuss duration and exit plans for hypnotics, especially benzodiazepines and Z-drugs.
If insomnia co-occurs with depression or suicidality, prioritize safety planning and treat the underlying condition.

Staying current with evidence

Use evidence filters to keep pace with guideline updates and newer randomized trials.

Evidence Library — daridorexant for DORA studies (switch drug to compare).
Evidence Library — guidelines to locate practice guideline summaries.
Check the updates log to see when key sleep content was last refreshed.

Medication index

Browse all medication pages covered by this hub. Use Compare for side-by-side decisions and Evidence for curated studies.

Frequently asked questions

What is the best first-line treatment for chronic insomnia?

For many people, CBT-I is first-line because it improves sleep long-term without medication side effects. Medications can be layered in when symptoms are severe, short-term relief is needed, or CBT-I is not accessible.

Are “Z-drugs” safer than benzodiazepines?

They are different, not risk-free. Z-drugs can still cause next-day impairment, falls, and rare complex sleep behaviors. Benzodiazepines add dependence and withdrawal risk. A clinician can help choose the lowest-risk option for your situation.

How often is this hub updated?

We refresh medication summaries, monitoring notes, and evidence links when labeling or guidelines change. The Evidence Library and Updates pages provide the quickest view of recent refreshes.