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Patient education: Insomnia treatments (Beyond the Basics)

Patient education: Insomnia treatments (Beyond the Basics)
Authors:
Jennifer L Martin, PhD
David N Neubauer, MD
Section Editor:
Ruth Benca, MD, PhD
Deputy Editor:
April F Eichler, MD, MPH
Literature review current through: Feb 2022. | This topic last updated: Jan 30, 2022.

INSOMNIA OVERVIEW — Insomnia is defined as difficulty falling asleep, difficulty staying asleep, or waking up early in the morning and not being able to fall back to sleep. In general, people with insomnia sleep less or sleep poorly despite having an adequate chance to sleep. Sleeping poorly or not enough makes it harder to function well during the daytime. Insomnia is not defined by the number of hours slept because different people need different amounts of sleep.

In some cases, insomnia is related to another problem, such as stress, pain, or a medical condition. In these cases, treating the underlying problem may help to improve sleep. In other cases, either the cause of insomnia is not clear or the insomnia does not get better when the underlying problem is treated. When this happens, there are ways to treat the insomnia itself. If you are struggling with insomnia, talk to your health care provider; they can work with you to identify any underlying issues and help you make a treatment plan.

This article discusses the available treatments for insomnia. More information about the symptoms and diagnosis of insomnia is available separately. (See "Patient education: Insomnia (Beyond the Basics)".)

COGNITIVE BEHAVIORAL THERAPY FOR INSOMNIA — Cognitive behavioral therapy for insomnia, or "CBT-I," is often recommended as the initial treatment for chronic insomnia (insomnia lasting for longer than three months). This may be sufficient in improving insomnia, although in some cases, medication is recommended as well (usually after first trying CBT-I). (See 'Medications for insomnia' below.)

CBT-I involves working with a therapist over several weeks to identify and address factors that contribute to insomnia and correct harmful sleep habits. Components of CBT-I include sleep education, sleep restriction or compression, stimulus control, sleep hygiene, cognitive therapy, and relaxation exercises. These are discussed in more detail below.

Sleep education — This involves working with a health care provider or therapist to learn about what happens during sleep and how insomnia can develop and persist.

Sleep restriction or sleep compression — Sleep restriction involves keeping track of how much time you spend in bed and how much of that time is spent sleeping versus awake. Often, people with insomnia spend extra time in bed to try to make up for lost sleep, then find that this makes it harder to fall asleep again the next night. This perpetuates the cycle of insomnia.

With sleep restriction, you work with a therapist to keep a "sleep diary" to better understand your habits. Then you set a specific schedule for when to go to bed and when to get up, and you keep to that schedule even if you don't sleep the whole time. This helps to make you tired enough to get more restful sleep on subsequent nights. As your sleep improves over time, you can increase the amount of time you spend in bed again. It's important to work with a professional if you are trying sleep restriction, as the process can make you feel more tired during the day at the beginning, which can be dangerous if you are trying to do activities that require you to be focused and alert.

"Sleep compression" is a similar approach that also involves keeping a sleep diary and setting a routine bedtime and wake time. However, it involves shortening the window of time in bed more gradually; this may be recommended for some people for whom sleep restriction may not be safe (for example, those with certain medical or psychiatric conditions).

Stimulus control — Stimulus control therapy is based on the idea that some people with insomnia associate their bedroom and bed with staying awake rather than sleeping. To help with this:

Go to bed only when you feel sleepy.

Use your bed and bedroom only for sleep and sex.

If you cannot fall asleep within about 20 minutes, get up, go to another room and read or find another relaxing activity until you feel sleepy again. Activities such as eating, balancing your checkbook, doing housework, watching TV, or studying for a test, which "reward" you for staying awake, should be avoided.

Do not nap during the day.

Sleep hygiene — Sleep hygiene teaches good sleeping habits (table 1). To practice good sleep hygiene:

Set a regular sleep schedule (the same bedtime and wake time every day). Sleep only as much as you need to feel rested, then get out of bed.

Avoid caffeine after lunch.

Avoid alcohol near bedtime.

Do not smoke (particularly during the evening).

Get regular exercise during the day, but try to avoid rigorous exercise within two hours of bedtime.

Keep your room quiet and dark. You can use a fan or white noise machine to help reduce noise, and blackout shades or an eye mask can help reduce light.

Avoid checking the time during the night.

Avoid looking at screens (including televisions, smartphones, laptops, and tablets) at bedtime. Light from screens can make it harder to fall asleep.

Avoid eating a large meal close to bedtime, but don't go to bed hungry. Try to eat a healthy and filling (but not too heavy) meal in the evening and avoid late-night snacks.

Cognitive therapy — People who are awake at night often become concerned that they will perform poorly the next day if they do not sleep enough, and they begin struggling with sleep. This can create a cycle where being awake at night increases your anxiety, which then makes it more difficult to sleep. You may begin to blame all negative events in your life on poor sleep.

During cognitive therapy, you work with a therapist to deal with negative thinking that contributes to sleep-related anxiety.

Relaxation exercises — Techniques to help with relaxation are often part of a CBT-I program. Common approaches include:

Progressive muscle relaxation – This involves progressively relaxing your muscles from your head down to your feet. Here is a sample of a relaxation program: Beginning with the muscles in your face, squeeze (contract) your muscles gently for one to two seconds and then relax. Repeat several times. Use the same technique for other muscle groups, usually in the following sequence (working your way down the body): jaw and neck, shoulders, upper arms, lower arms, fingers, chest, abdomen, buttocks, thighs, calves, and feet.

Diaphragmatic breathing – This is a deep breathing technique that can help you relax. The table includes instructions for how to do this (table 2).

Mindfulness – This involves trying to be present in the moment and aware of your physical sensations, thoughts, and emotions.

MEDICATIONS FOR INSOMNIA — If cognitive behavioral therapy for insomnia (CBT-I) is not sufficient and your insomnia interferes with your ability to function during the daytime, your health care provider may suggest trying medication. For people with chronic (long-term) insomnia, medication is typically used in addition to (rather than in place of) CBT-I, and the treatment approach should also involve identifying and addressing any underlying health issues that may contribute to insomnia.

If your provider recommends medication, your options will depend on:

Your age

Whether you have underlying health issues or take other medications

Your main insomnia symptom, that is, whether you mostly have trouble falling asleep or you mostly have trouble staying asleep during the night

Your provider can talk to you about the potential benefits of each medication (for example, improved daytime symptoms and function) as well as the risks (for example, bothersome side effects and the potential for dependence). In deciding on treatment, you will also need to consider cost as well as burden (that is, how and how often you need to take the medication). Some people are able to stop taking medication after their insomnia has improved, while others need to continue treatment longer-term.

The main categories of medication that are approved for the treatment of insomnia are:

Benzodiazepine receptor agonists (BZRAs)

Dual orexin receptor antagonists (DORAs)

Histamine receptor antagonists

Melatonin receptor agonists

These are discussed more below.

Benzodiazepine receptor agonists (BRZAs) — This category includes older drugs called benzodiazepines that used to be used more commonly for treating insomnia, as well as several nonbenzodiazepine BZRAs. All of these are "sedative-hypnotic" medications, meaning they work on the brain to make you feel sleepy.

Benzodiazepines – These are an older type of prescription medicine that cause sedation, muscle relaxation, and can lower anxiety levels. In the United States, those approved for the treatment of insomnia include quazepam (brand name: Doral), triazolam (brand name: Halcion), estazolam (brand name: ProSom), temazepam (brand name: Restoril), and flurazepam (brand name: Dalmane).

The older benzodiazepines are no longer recommended for the initial treatment of insomnia, as they are associated with a risk of dependence. They also take a while to wear off, so you may still be sleepy in the morning, which can be dangerous if you need to drive, work, or do other things that require you to be alert.

Nonbenzodiazepines – These are prescription medications that are somewhat similar to benzodiazepines. They may have fewer side effects compared with benzodiazepines because they work more on sleep centers and less on other areas of the brain. They tend to be short acting, so they are also less likely to make you still feel sleepy in the morning. Some can also be prescribed for a longer period of time.

Nonbenzodiazepines used to treat insomnia include zaleplon (brand name: Sonata), eszopiclone (brand name: Lunesta), zolpidem (brand name: Ambien), and zolpidem extended release (brand name: Ambien CR). Zolpidem is also available as a dissolving tablet (brand name: Edluar), an oral liquid spray (brand name: Zolpimist), and as a dissolving tablet at a lower dose for middle of the night use (brand name: Intermezzo).

Unusual behaviors such as eating, driving, or having sex after going to sleep have been reported after taking nonbenzodiazepines. You may have no memory of this behavior. While this does not always lead to harm, it can cause injury to yourself or others if you do something unsafe in your sleep. There is an increased risk of these unusual behaviors if you take the sleeping medicine after drinking alcohol or taking narcotic pain medicines. If you have this type of side effect, or if someone else notices that you are having unusual behaviors during sleep, stop taking the medicine immediately and let your health care provider know.

If you take one of the BRZAs, it's important to follow instructions carefully, and avoid combining them with alcohol or other sedative drugs.

Dual orexin receptor antagonists (DORAs) — This group of medications includes lemborexant (brand name: DayVigo), suvorexant (brand name: Belsomra), and daridorexant (brand name: Quviviq). They work by blocking a brain chemical called orexin. Under normal conditions, orexin helps you to stay awake.

The most common side effect of DORAs is drowsiness the next day. It's important to be cautious because morning drowsiness can affect driving safety, job performance, and decision-making.

Histamine receptor antagonists — The medication in this category used for treating insomnia is low-dose doxepin (brand name: Silenor). Doxepin is also used in the treatment of depression, but typically in higher doses. In addition to sleepiness, side effects may include nausea and upper respiratory tract infection.

Melatonin receptor agonists — The melatonin receptor agonist used for treating insomnia is ramelteon (brand name: Rozerem). This works in a similar way to melatonin supplements, but is a prescription medicine and has been more thoroughly studied. (See 'Melatonin' below.)

Ramelteon works best for people who have difficulty falling asleep. It is unlikely to cause morning sleepiness or to be habit-forming. Common side effects include dizziness, fatigue, and nausea.

Over-the-counter sleep aids — Many different products claim to relieve insomnia and are sold without a prescription. However, while these may be helpful if you occasionally have trouble falling asleep, they are generally not recommended for the treatment of chronic insomnia.

Antihistamines — Non-prescription sleep aids include various products containing either doxylamine or diphenhydramine (sample brand names: Benadryl, Nytol, ZzzQuil). Some products contain diphenhydramine plus a pain reliever like acetaminophen or ibuprofen.

There is little evidence that these sleep aids are beneficial for treating chronic insomnia. Antihistamines can cause daytime sleepiness and other side effects, such as dry mouth, blurred vision, and difficulty emptying the bladder. Especially in older adults, they can also cause confusion or memory problems.

Melatonin — Melatonin is a hormone that is normally produced by a gland in the brain. It might help some people who have trouble falling asleep (if taken a few hours before bedtime).

Melatonin appears to be safe when used for less than three months. However, as it is marketed as a dietary supplement in the United States, the ingredients, dose, and purity of dietary supplements are not regulated.

ALCOHOL AND SLEEP — People commonly use alcohol as a sleep aid. However, while it may help you fall asleep more quickly, alcohol often interferes with sleep later in the night. If you stop drinking alcohol after using it on a regular basis, you may develop severe insomnia.

People with insomnia should not drink alcohol near bedtime. All people should be aware of the health risks associated with alcohol, and exercise moderation if they choose to drink. (See "Patient education: Risks and benefits of alcohol (Beyond the Basics)".)

WHERE TO GET MORE INFORMATION — Your healthcare provider is the best source of information for questions and concerns related to your medical problem.

This article will be updated as needed on our web site (www.uptodate.com/patients). Related topics for patients, as well as selected articles written for healthcare professionals, are also available. Some of the most relevant are listed below.

Patient level information — UpToDate offers two types of patient education materials.

The Basics — The Basics patient education pieces answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials.

Patient education: Insomnia (The Basics)
Patient education: Daytime sleepiness (The Basics)
Patient education: Jet lag (The Basics)
Patient education: What is a sleep study? (The Basics)

Beyond the Basics — Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are best for patients who want in-depth information and are comfortable with some medical jargon.

Patient education: Insomnia (Beyond the Basics)
Patient education: Anaphylaxis symptoms and diagnosis (Beyond the Basics)
Patient education: Depression treatment options for adults (Beyond the Basics)

Professional level information — Professional level articles are designed to keep doctors and other health professionals up-to-date on the latest medical findings. These articles are thorough, long, and complex, and they contain multiple references to the research on which they are based. Professional level articles are best for people who are comfortable with a lot of medical terminology and who want to read the same materials their doctors are reading.

Classification of sleep disorders
Risk factors, comorbidities, and consequences of insomnia in adults
Evaluation and diagnosis of insomnia in adults
Overview of the treatment of insomnia in adults
Cognitive behavioral therapy for insomnia in adults
Pharmacotherapy for insomnia in adults

The following organizations also provide reliable health information.

National Library of Medicine

     (medlineplus.gov/sleepdisorders.html)

American Academy of Sleep Medicine

     (https://aasm.org/)

National Heart, Lung, and Blood Institute

     (www.nhlbi.nih.gov/health/resources/sleep)

This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof. The use of this information is governed by the Terms of Use, available at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms ©2022 UpToDate, Inc. and its affiliates and/or licensors. All rights reserved.
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