| Insomnia symptom | Patient complaint(s) | Follow-up question(s) | Possible alternative diagnosis or comorbidity (if yes) | Next steps |
| Sleep onset difficulty | I can't fall asleep at night. I can lie in bed for hours and not fall asleep. | Do your legs bother you when you are sitting or lying down? | Restless legs syndrome | Check iron stores, consider pharmacotherapy for restless legs syndrome (eg, iron supplementation, dopamine agonists, gabapentinoids) |
| When you are on vacation, do you tend to stay up late and sleep late? Do you consider yourself a "night owl"? If you go to bed later, do you fall asleep more easily? Do you have trouble waking up in the morning? | Delayed sleep-wake phase disorder | Sleep log and/or actigraphy for review of sleep-wake patterns on weekdays and weekends | ||
| Sleep maintenance difficulty, daytime sleepiness | I often wake up in the middle of the night. I can't keep my eyes open during the day, even though I am getting enough sleep. | Do you snore loudly? Does your partner witness pauses in your breathing while you sleep? | Sleep apnea | Polysomnography or home sleep apnea testing |
| Are you a restless sleeper? Have you been told you have limb movements or muscle twitches during sleep? | Periodic limb movements | Polysomnography | ||
| Early morning awakening | I wake up too early in the morning and can't get back to sleep. | Do you nod off in the early evening or have to force yourself to stay awake for evening activities? | Advanced sleep-wake phase disorder | Sleep log and/or actigraphy for review of sleep-wake patterns on weekdays and weekends |
| Do you feel down, depressed, or hopeless? Have you lost interest or pleasure in doing things?* | Depression | Evaluate for depression; concomitant treatment for both disorders is often necessary to hasten recovery and increase the likelihood of sustained response | ||
| Decreased sleep quantity | I try to get enough sleep, but I can't keep my eyes open during the day. I sometimes nod off at work or when I'm driving. | Do you have family, social, or job obligations that prevent you from getting enough sleep on a regular basis? Do you depend on an alarm to wake up in the morning? Do you catch up on sleep on the weekends? | Insufficient sleep | Emphasize sleep hygiene and lifestyle changes to promote adequate sleep |
| I can't seem to sleep for more than six hours per night, but I'm not tired during the day. | Have you always seemed to need less sleep than other people your age? | Short sleep duration | Educate about range of normal sleep need, revise expectations on sleep quantity |
