Guidelines Summary

Low-value care

In 2014, as part of the Choosing Wisely® initiative from the American Board of Internal Medicine Foundation (ABIM), the AASM recommended that physicians avoid polysomnography (PSG) in patients with chronic insomnia unless symptoms suggest a comorbid sleep disorder. It further recommended that hypnotics be avoided as primary therapy for chronic insomnia in adults. Instead, clinicians should offer cognitive-behavioral therapy (CBT), reserving medication for adjunctive treatment when necessary.^[111]

Evaluation

The American Academy of Sleep Medicine (AASM) guideline consensus is that insomnia is primarily diagnosed by clinical evaluation through a thorough sleep history and detailed medical, substance, and psychiatric history. At a minimum, patients should complete the following evaluations:^[1]

A general medical and psychiatric questionnaire to detect comorbid disorders
A sleepiness assessment, such as the Epworth Sleepiness Scale
A 2-week sleep log to define sleep-wake patterns and their variability

Sleep diary data should be collected before and during the course of active treatment and in the case of relapse or reevaluation in the long term.

Other testing (eg, blood, imaging studies) is not indicated for the routine evaluation of chronic insomnia unless there is suspicion for comorbid disorders.

Achieving healthy sleep

In 2015, the American Thoracic Society (ATS) released a policy statement stressing the importance of achieving good-quality sleep and avoiding sleep deprivation. Key recommendations include the following:^[112]

Good-quality sleep is critical for good health and overall quality of life
Short sleep duration (6 hours or less per 24-hour period) is associated with adverse outcomes, including mortality
Long sleep duration (>9 to 10 hours per 24-hour period) may also be associated with adverse health outcomes
At a population level, the optimal sleep duration in adults for good health is 7 to 9 hours, although individual variability exists
Because drowsy driving is an important cause of fatal and nonfatal motor vehicle crashes, all drivers (occupational and nonoccupational) should receive education about how to recognize the symptoms and consequences of drowsiness
Better education is needed for the general public and healthcare providers regarding the effect of working hours and shift work on sleep duration and quality and the association of sleepiness with workplace injuries
Sleep disorders are common, cause significant morbidity, and have substantial economic impact, but they are treatable; however, many individuals with sleep disorders remain undiagnosed and untreated
Age-based recommendations for sleep duration in children should be developed; these should enable the child to awaken spontaneously at the desired time through implementation of regular wake and sleep schedules
For adolescents, school start times should be delayed to align with the physiologic circadian propensity of this age group
Healthcare providers should receive more education on sleep hygiene and encourage patients to maximize their sleep time
Public education programs should be developed to emphasize the importance of sleep for good health
Better education/awareness is needed of the importance of early identification of groups at high risk for obstructive sleep apnea (in children and adults)
Better education of physicians as to the effectiveness of cognitive-behavior therapy for insomnia rather than immediate implementation of hypnotics and sedatives, and structural changes to increase access to this therapy

Pharmacological treatment for chronic insomnia

The following recommendations from the American Academy of Sleep Medicine (AASM) are intended as a guideline for clinicians in choosing a specific pharmacological agent for treatment of chronic insomnia in adults, when such treatment is indicated.^[3]

For patients with primary insomnia (psychophysiologic, idiopathic or paradoxical ICSD-2 subtypes), when pharmacologic treatment is utilized alone or in combination therapy, the recommended general sequence of medication trials is as follows:

Short-intermediate acting benzodiazepine receptor agonists (BZD or newer BzRAs) or ramelteon—zolpidem, eszopiclone, zaleplon, and temazepam
Alternate short-intermediate acting BzRAs or ramelteon if the initial agent has been unsuccessful
Sedating antidepressants, especially when used in conjunction with treating comorbid depression/anxiety—trazodone, amitriptyline, doxepin, and mirtazapine
Combined BzRA or ramelteon and sedating antidepressant
Other sedating agents—anti-epilepsy medications (gabapentin, tiagabine) and atypical antipsychotics (quetiapine and olanzapine)

Medication

[Guideline] Schutte-Rodin S, Broch L, Buysse D, Dorsey C, Sateia M. Clinical guideline for the evaluation and management of chronic insomnia in adults. J Clin Sleep Med. 2008 Oct 15. 4(5):487-504. [QxMD MEDLINE Link]. [Full Text].
Montagna P, Gambetti P, Cortelli P, Lugaresi E. Familial and sporadic fatal insomnia. Lancet Neurol. 2003 Mar. 2(3):167-76. [QxMD MEDLINE Link].
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15. 13 (2):307-349. [QxMD MEDLINE Link].
Edinger JD, Means MK. Cognitive-behavioral therapy for primary insomnia. Clin Psychol Rev. 2005 Jul. 25(5):539-58. [QxMD MEDLINE Link].
Chesson AL Jr, Anderson WM, Littner M, Davila D, Hartse K, Johnson S, et al. Practice parameters for the nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 1999 Dec 15. 22(8):1128-33. [QxMD MEDLINE Link].
Morgenthaler T, Kramer M, Alessi C, Friedman L, Boehlecke B, Brown T, et al. Practice parameters for the psychological and behavioral treatment of insomnia: an update. An american academy of sleep medicine report. Sleep. 2006 Nov 1. 29(11):1415-9. [QxMD MEDLINE Link].
Sateia MJ, Buysse DJ, Krystal AD, Neubauer DN, Heald JL. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. J Clin Sleep Med. 2017 Feb 15. 13 (2):307-349. [QxMD MEDLINE Link].
American Academy of Sleep Medicine. ICSD2 - International Classification of Sleep Disorders. Diagnostic and Coding Manual. 2nd. Westchester, Ill: American Academy of Sleep Medicine; 2005. 1-32.
Buysse DJ. Diagnosis and Classification of Insomnia Disorders. In: Insomnia: Principles and Management. Szuba MP, Kloss JD, Dinges DF, Eds. Cambridge University Press, Cambridge UK, 2003, et al.
Chokroverty S. Sleep Disorders Medicine: Basic Science, Technical Considerations, and Clinical Aspects, 3rd edition, p361. WB Saunders, Philadelphia, et al.
The Gallup organization. The Gallup study of sleeping habits. Princeton, NJ,: The Gallup Organization; 1979.
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. Fifth. Arlington, VA: American Psychiatric Association; 2013.
Edinger JD, Means MK, Carney CE, Krystal AD. Psychomotor performance deficits and their relation to prior nights' sleep among individuals with primary insomnia. Sleep. 2008 May 1. 31(5):599-607. [QxMD MEDLINE Link]. [Full Text].
Zammit GK, Weiner J, Damato N, Sillup GP, McMillan CA. Quality of life in people with insomnia. Sleep. 1999 May 1. 22 Suppl 2:S379-85. [QxMD MEDLINE Link].
Daley M, Morin CM, LeBlanc M, Grégoire JP, Savard J. The economic burden of insomnia: direct and indirect costs for individuals with insomnia syndrome, insomnia symptoms, and good sleepers. Sleep. 2009 Jan 1. 32(1):55-64. [QxMD MEDLINE Link]. [Full Text].
National Institutes of Health State of the Science Conference statement on Manifestations and Management of Chronic Insomnia in Adults, June 13-15, 2005. Sleep. 2005 Sep 1. 28(9):1049-57. [QxMD MEDLINE Link].
Smith MT, Huang MI, Manber R. Cognitive behavior therapy for chronic insomnia occurring within the context of medical and psychiatric disorders. Clin Psychol Rev. 2005 Jul. 25(5):559-92. [QxMD MEDLINE Link].
Morin CM, Bootzin RR, Buysse DJ, Edinger JD, Espie CA, Lichstein KL. Psychological and behavioral treatment of insomnia:update of the recent evidence (1998-2004). Sleep. 2006 Nov 1. 29(11):1398-414. [QxMD MEDLINE Link].
Czeisler CA, Cajochen C, Turek FW. Melatonin in the regulation of sleep and circadian rhythms. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. New York: McGraw-Hill; 2000. 400-6.
Saper CB, Scammell TE, Lu J. Hypothalamic regulation of sleep and circadian rhythms. Nature. 2005 Oct 27. 437(7063):1257-63. [QxMD MEDLINE Link].
Saper CB, Chou TC, Scammell TE. The sleep switch: hypothalamic control of sleep and wakefulness. Trends Neurosci. 2001 Dec. 24(12):726-31. [QxMD MEDLINE Link].
Baumann CR, Bassetti CL. Hypocretins (orexins) and sleep-wake disorders. Lancet Neurol. 2005 Oct. 4(10):673-82. [QxMD MEDLINE Link].
Lu J, Greco MA. Sleep circuitry and the hypnotic mechanism of GABAA drugs. J Clin Sleep Med. 2006 Apr 15. 2(2):S19-26. [QxMD MEDLINE Link].
Nutt D. GABAA receptors: subtypes, regional distribution, and function. J Clin Sleep Med. 2006 Apr 15. 2(2):S7-11. [QxMD MEDLINE Link].
Krystal A. Pharmacological Treatment: Other Medications. Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 5th ed. St. Louis, Mo: Elsevier Saunders; 2010. 916-30.
Drake CL and Roth T. Predisposition in the Evolution of Insomnia: Evidence, Potential Mechanisms, and Future Directions. Sleep Med Clin. 2006. 1(3):333-350.
Nofzinger EA, Buysse DJ, Germain A, Price JC, Miewald JM, Kupfer DJ. Functional neuroimaging evidence for hyperarousal in insomnia. Am J Psychiatry. 2004 Nov. 161(11):2126-8. [QxMD MEDLINE Link].
Bonnet MH, Arand DL. 24-Hour metabolic rate in insomniacs and matched normal sleepers. Sleep. 1995 Sep. 18(7):581-8. [QxMD MEDLINE Link].
Bonnet MH, Arand DL. Caffeine use as a model of acute and chronic insomnia. Sleep. 1992 Dec. 15(6):526-36. [QxMD MEDLINE Link].
Vgontzas AN, Bixler EO, Lin HM, Prolo P, Mastorakos G, Vela-Bueno A, et al. Chronic insomnia is associated with nyctohemeral activation of the hypothalamic-pituitary-adrenal axis: clinical implications. J Clin Endocrinol Metab. 2001 Aug. 86(8):3787-94. [QxMD MEDLINE Link].
Lack LC, Gradisar M, Van Someren EJ, Wright HR, Lushington K. The relationship between insomnia and body temperatures. Sleep Med Rev. 2008 Aug. 12(4):307-17. [QxMD MEDLINE Link].
Spielman AJ, Caruso LS, Glovinsky PB. A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec. 10(4):541-53. [QxMD MEDLINE Link].
Crocker A, Sehgal A. Genetic analysis of sleep. Genes Dev. 2010 Jun 15. 24(12):1220-35. [QxMD MEDLINE Link]. [Full Text].
Rétey JV, Adam M, Khatami R, Luhmann UF, Jung HH, Berger W, et al. A genetic variation in the adenosine A2A receptor gene (ADORA2A) contributes to individual sensitivity to caffeine effects on sleep. Clin Pharmacol Ther. 2007 May. 81(5):692-8. [QxMD MEDLINE Link].
Hamet P, Tremblay J. Genetics of the sleep-wake cycle and its disorders. Metabolism. 2006 Oct. 55(10 Suppl 2):S7-12. [QxMD MEDLINE Link].
Buhr A, Bianchi MT, Baur R, Courtet P, Pignay V, Boulenger JP, et al. Functional characterization of the new human GABA(A) receptor mutation beta3(R192H). Hum Genet. 2002 Aug. 111(2):154-60. [QxMD MEDLINE Link].
Montagna P, Cortelli P, Tinuper P, et al. Fatal familial insomnia. Guilleminault C, Montagna P, Lugaresi E, Gambetti P, editors. Fatal Familial Insomnia: Inherited Prion Disease, Sleep and the Thalamus. New York, NY: Raven Press; 1994. 1–14.
Gambetti O, Medori P, Manetto V, et al. Fatal familial insomnia: S prion disease with distinctive histopathological and genotypic features. Guilleminault C, Montagna P, Lugaresi E, Gambetti P, editors. Fatal Familial Insomnia Inherited Prion Disease, Sleep and the Thalamus. New York, NY: Raven Press; 1994. 7–32.
Montagna P, Cortelli P, Avoni P, Tinuper P, Plazzi G, Gallassi R, et al. Clinical features of fatal familial insomnia: phenotypic variability in relation to a polymorphism at codon 129 of the prion protein gene. Brain Pathol. 1998 Jul. 8(3):515-20. [QxMD MEDLINE Link].
Goldfarb LG, Petersen RB, Tabaton M, Brown P, LeBlanc AC, Montagna P, et al. Fatal familial insomnia and familial Creutzfeldt-Jakob disease: disease phenotype determined by a DNA polymorphism. Science. 1992 Oct 30. 258(5083):806-8. [QxMD MEDLINE Link].
Scaravilli F, Cordery RJ, Kretzschmar H, Gambetti P, Brink B, Fritz V, et al. Sporadic fatal insomnia: a case study. Ann Neurol. 2000 Oct. 48(4):665-8. [QxMD MEDLINE Link].
Morin CM, Rodrigue S, Ivers H. Role of stress, arousal, and coping skills in primary insomnia. Psychosom Med. 2003 Mar-Apr. 65(2):259-67. [QxMD MEDLINE Link].
Ford DE, Kamerow DB. Epidemiologic study of sleep disturbances and psychiatric disorders. An opportunity for prevention?. JAMA. 1989 Sep 15. 262(11):1479-84. [QxMD MEDLINE Link].
Insomnia. American Academy of Sleep Medicine. The International Classification of Sleep Disorders. 2nd ed. Westchester, Illinois: American Academy of Sleep Medicine; 2005. 1-31.
Taylor DJ, Mallory LJ, Lichstein KL, Durrence HH, Riedel BW, Bush AJ. Comorbidity of chronic insomnia with medical problems. Sleep. 2007 Feb 1. 30(2):213-8. [QxMD MEDLINE Link].
Johnson EO, Roth T, Schultz L, Breslau N. Epidemiology of DSM-IV insomnia in adolescence: lifetime prevalence, chronicity, and an emergent gender difference. Pediatrics. 2006 Feb. 117(2):e247-56. [QxMD MEDLINE Link].
Ohayon MM. Epidemiology of insomnia: what we know and what we still need to learn. Sleep Med Rev. 2002 Apr. 6(2):97-111. [QxMD MEDLINE Link].
Liu Y, Wheaton AG, Chapman DP, Cunningham TJ, Lu H, Croft JB. Prevalence of Healthy Sleep Duration among Adults - United States, 2014. MMWR Morb Mortal Wkly Rep. 2016 Feb 19. 65 (6):137-41. [QxMD MEDLINE Link].
Morin CM, LeBlanc M, Daley M, Gregoire JP, Mérette C. Epidemiology of insomnia: prevalence, self-help treatments, consultations, and determinants of help-seeking behaviors. Sleep Med. 2006 Mar. 7(2):123-30. [QxMD MEDLINE Link].
Calem M, Bisla J, Begum A, Dewey M, Bebbington PE, Brugha T, et al. Increased prevalence of insomnia and changes in hypnotics use in England over 15 years: analysis of the 1993, 2000, and 2007 National Psychiatric Morbidity Surveys. Sleep. 2012 Mar 1. 35(3):377-84. [QxMD MEDLINE Link]. [Full Text].
Zhang B, Wing YK. Sex differences in insomnia: a meta-analysis. Sleep. 2006 Jan 1. 29(1):85-93. [QxMD MEDLINE Link].
Kravitz HM, Ganz PA, Bromberger J, Powell LH, Sutton-Tyrrell K, Meyer PM. Sleep difficulty in women at midlife: a community survey of sleep and the menopausal transition. Menopause. 2003 Jan-Feb. 10(1):19-28. [QxMD MEDLINE Link].
Strine TW, Chapman DP, Ahluwalia IB. Menstrual-related problems and psychological distress among women in the United States. J Womens Health (Larchmt). 2005 May. 14(4):316-23. [QxMD MEDLINE Link].
Ruiter ME, DeCoster J, Jacobs L, Lichstein KL. Sleep disorders in African Americans and Caucasian Americans: a meta-analysis. Behav Sleep Med. 2010. 8(4):246-59. [QxMD MEDLINE Link].
Monane M. Insomnia in the elderly. J Clin Psychiatry. 1992 Jun. 53 Suppl:23-8. [QxMD MEDLINE Link].
Krystal AD. Treating the health, quality of life, and functional impairments in insomnia. J Clin Sleep Med. 2007 Feb 15. 3(1):63-72. [QxMD MEDLINE Link].
Chien KL, Chen PC, Hsu HC, Su TC, Sung FC, Chen MF, et al. Habitual sleep duration and insomnia and the risk of cardiovascular events and all-cause death: report from a community-based cohort. Sleep. 2010 Feb 1. 33(2):177-84. [QxMD MEDLINE Link]. [Full Text].
Phillips B, Buzková P, Enright P. Insomnia did not predict incident hypertension in older adults in the cardiovascular health study. Sleep. 2009 Jan 1. 32(1):65-72. [QxMD MEDLINE Link]. [Full Text].
Gangwisch JE, Heymsfield SB, Boden-Albala B, Buijs RM, Kreier F, Pickering TG, et al. Short sleep duration as a risk factor for hypertension: analyses of the first National Health and Nutrition Examination Survey. Hypertension. 2006 May. 47(5):833-9. [QxMD MEDLINE Link].
Gottlieb DJ, Redline S, Nieto FJ, Baldwin CM, Newman AB, Resnick HE, et al. Association of usual sleep duration with hypertension: the Sleep Heart Health Study. Sleep. 2006 Aug 1. 29(8):1009-14. [QxMD MEDLINE Link].
Vgontzas AN, Liao D, Bixler EO, Chrousos GP, Vela-Bueno A. Insomnia with objective short sleep duration is associated with a high risk for hypertension. Sleep. 2009 Apr 1. 32(4):491-7. [QxMD MEDLINE Link]. [Full Text].
Lanfranchi PA, Pennestri MH, Fradette L, Dumont M, Morin CM, Montplaisir J. Nighttime blood pressure in normotensive subjects with chronic insomnia: implications for cardiovascular risk. Sleep. 2009 Jun 1. 32(6):760-6. [QxMD MEDLINE Link]. [Full Text].
Knutson KL, Van Cauter E, Rathouz PJ, Yan LL, Hulley SB, Liu K, et al. Association between sleep and blood pressure in midlife: the CARDIA sleep study. Arch Intern Med. 2009 Jun 8. 169(11):1055-61. [QxMD MEDLINE Link]. [Full Text].
Baglioni C, Battagliese G, Feige B, Spiegelhalder K, Nissen C, Voderholzer U, et al. Insomnia as a predictor of depression: a meta-analytic evaluation of longitudinal epidemiological studies. J Affect Disord. 2011 Dec. 135(1-3):10-9. [QxMD MEDLINE Link].
Ohayon MM, Roth T. Place of chronic insomnia in the course of depressive and anxiety disorders. J Psychiatr Res. 2003 Jan-Feb. 37(1):9-15. [QxMD MEDLINE Link].
Chesson A Jr, Hartse K, Anderson WM, Davila D, Johnson S, Littner M, et al. Practice parameters for the evaluation of chronic insomnia. An American Academy of Sleep Medicine report. Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2000 Mar 15. 23(2):237-41. [QxMD MEDLINE Link].
Natale V, Plazzi G, Martoni M. Actigraphy in the assessment of insomnia: a quantitative approach. Sleep. 2009 Jun 1. 32(6):767-71. [QxMD MEDLINE Link]. [Full Text].
Irwin MR, Carrillo C, Sadeghi N, Bjurstrom MF, Breen EC, Olmstead R. Prevention of Incident and Recurrent Major Depression in Older Adults With Insomnia: A Randomized Clinical Trial. JAMA Psychiatry. 2021 Nov 24. [QxMD MEDLINE Link].
Morin CM, Hauri PJ, Espie CA, Spielman AJ, Buysse DJ, Bootzin RR. Nonpharmacologic treatment of chronic insomnia. An American Academy of Sleep Medicine review. Sleep. 1999 Dec 15. 22(8):1134-56. [QxMD MEDLINE Link].
Jacobs GD, Pace-Schott EF, Stickgold R, Otto MW. Cognitive behavior therapy and pharmacotherapy for insomnia: a randomized controlled trial and direct comparison. Arch Intern Med. 2004 Sep 27. 164(17):1888-96. [QxMD MEDLINE Link].
Irwin MR, Cole JC, Nicassio PM. Comparative meta-analysis of behavioral interventions for insomnia and their efficacy in middle-aged adults and in older adults 55+ years of age. Health Psychol. 2006 Jan. 25(1):3-14. [QxMD MEDLINE Link].
Manber R, Edinger JD, Gress JL, San Pedro-Salcedo MG, Kuo TF, Kalista T. Cognitive behavioral therapy for insomnia enhances depression outcome in patients with comorbid major depressive disorder and insomnia. Sleep. 2008 Apr 1. 31(4):489-95. [QxMD MEDLINE Link]. [Full Text].
Edinger JD, Wohlgemuth WK, Radtke RA, Coffman CJ, Carney CE. Dose-response effects of cognitive-behavioral insomnia therapy: a randomized clinical trial. Sleep. 2007 Feb 1. 30(2):203-12. [QxMD MEDLINE Link].
Buysse DJ, Germain A, Moul DE, et al. Efficacy of brief behavioral treatment for chronic insomnia in older adults. Arch Intern Med. 2011 May 23. 171(10):887-95. [QxMD MEDLINE Link]. [Full Text].
Morin CM, Beaulieu-Bonneau S, LeBlanc M, Savard J. Self-help treatment for insomnia: a randomized controlled trial. Sleep. 2005 Oct 1. 28(10):1319-27. [QxMD MEDLINE Link].
Sivertsen B, Omvik S, Pallesen S, Bjorvatn B, Havik OE, Kvale G, et al. Cognitive behavioral therapy vs zopiclone for treatment of chronic primary insomnia in older adults: a randomized controlled trial. JAMA. 2006 Jun 28. 295(24):2851-8. [QxMD MEDLINE Link].
Morin CM, Vallieres A, Guay B, Ivers H, Savard J, Merette C, et al. Cognitive behavioral therapy, singly and combined with medication, for persistent insomnia. JAMA. May 20 2009. 301(19):2005-15.
Krystal AD, Walsh JK, Laska E, Caron J, Amato DA, Wessel TC, et al. Sustained efficacy of eszopiclone over 6 months of nightly treatment: results of a randomized, double-blind, placebo-controlled study in adults with chronic insomnia. Sleep. 2003 Nov 1. 26(7):793-9. [QxMD MEDLINE Link].
Walsh JK, Krystal AD, Amato DA, Rubens R, Caron J, Wessel TC, et al. Nightly treatment of primary insomnia with eszopiclone for six months: effect on sleep, quality of life, and work limitations. Sleep. 2007 Aug 1. 30(8):959-68. [QxMD MEDLINE Link]. [Full Text].
Roth T, Walsh JK, Krystal A, Wessel T, Roehrs TA. An evaluation of the efficacy and safety of eszopiclone over 12 months in patients with chronic primary insomnia. Sleep Med. 2005 Nov. 6(6):487-95. [QxMD MEDLINE Link].
Krystal AD, Erman M, Zammit GK, Soubrane C, Roth T. Long-term efficacy and safety of zolpidem extended-release 12.5 mg, administered 3 to 7 nights per week for 24 weeks, in patients with chronic primary insomnia: a 6-month, randomized, double-blind, placebo-controlled, parallel-group, multicenter study. Sleep. 2008 Jan 1. 31(1):79-90. [QxMD MEDLINE Link]. [Full Text].
Jeffrey S. FDA recommends lower bedtime dose for zolpidem. Medscape Medical News. Jan 10, 2013. Available at http://www.medscape.com/viewarticle/777431. Accessed: Jan 16, 2013.
FDA Drug Safety Communication: Risk of next-morning impairment after use of insomnia drugs; FDA requires lower recommended doses for certain drugs containing zolpidem (Ambien, Ambien CR, Edluar, and ZolpiMist). US Food and Drug Administration. Available at http://www.fda.gov/Drugs/DrugSafety/ucm334033.htm. Accessed: January 10, 2013.
Jeffrey S. FDA label changes for zolpidem products. Medcape Medical News. May 14, 2013. [Full Text].
De Crescenzo F, D'Alò GL, Ostinelli EG, Ciabattini M, Di Franco V, Watanabe N, et al. Comparative effects of pharmacological interventions for the acute and long-term management of insomnia disorder in adults: a systematic review and network meta-analysis. Lancet. 2022 Jul 16. 400 (10347):170-184. [QxMD MEDLINE Link].
Morgenthaler TI, Silber MH. Amnestic sleep-related eating disorder associated with zolpidem. Sleep Med. 2002 Jul. 3(4):323-7. [QxMD MEDLINE Link].
Chiang A, Krystal A. Report of two cases where sleep related eating behavior occurred with the extended-release formulation but not the immediate-release formulation of a sedative-hypnotic agent. J Clin Sleep Med. 2008 Apr 15. 4(2):155-6. [QxMD MEDLINE Link]. [Full Text].
Roehrs TA, Randall S, Harris E, Maan R, Roth T. Twelve months of nightly zolpidem does not lead to dose escalation: a prospective placebo-controlled study. Sleep. 2011 Feb 1. 34(2):207-12. [QxMD MEDLINE Link]. [Full Text].
Dayvigo (lemborexant) [package insert]. Woodcliff Lake, NJ: Eisai Inc. December 2019. Available at [Full Text].
Quviviq (daridorexant) [package insert]. Radnor, PA: Idorsia Pharmaceuticals US Inc. January 2022. Available at [Full Text].
Zammit G, Erman M, Wang-Weigand S, Sainati S, Zhang J, Roth T. Evaluation of the efficacy and safety of ramelteon in subjects with chronic insomnia. J Clin Sleep Med. 2007 Aug 15. 3(5):495-504. [QxMD MEDLINE Link]. [Full Text].
Zammit G, Wang-Weigand S, Rosenthal M, Peng X. Effect of ramelteon on middle-of-the-night balance in older adults with chronic insomnia. J Clin Sleep Med. 2009 Feb 15. 5(1):34-40. [QxMD MEDLINE Link]. [Full Text].
Mayer G, Wang-Weigand S, Roth-Schechter B, Lehmann R, Staner C, Partinen M. Efficacy and safety of 6-month nightly ramelteon administration in adults with chronic primary insomnia. Sleep. 2009 Mar 1. 32(3):351-60. [QxMD MEDLINE Link]. [Full Text].
Roth T, Heith Durrence H, Jochelson P, Peterson G, Ludington E, Rogowski R, et al. Efficacy and safety of doxepin 6 mg in a model of transient insomnia. Sleep Med. 2010 Oct. 11(9):843-7. [QxMD MEDLINE Link].
Krystal AD, Durrence HH, Scharf M, Jochelson P, Rogowski R, Ludington E, et al. Efficacy and Safety of Doxepin 1 mg and 3 mg in a 12-week Sleep Laboratory and Outpatient Trial of Elderly Subjects with Chronic Primary Insomnia. Sleep. 2010 Nov. 33(11):1553-61. [QxMD MEDLINE Link]. [Full Text].
Zhang D, Tashiro M, Shibuya K, et al. Next-day residual sedative effect after nighttime administration of an over-the-counter antihistamine sleep aid, diphenhydramine, measured by positron emission tomography. J Clin Psychopharmacol. 2010 Dec;30(6):694... Zhang D, Tashiro M, Shibuya K, et al. Next-day residual sedative effect after nighttime administration of an over-the-counter antihistamine sleep aid, diphenhydramine, measured by positron emission tomography. J Clin Psychopharmacol. 2010 Dec;30(6):694-701.
Brzezinski A, Vangel MG, Wurtman RJ, Norrie G, Zhdanova I, Ben-Shushan A, et al. Effects of exogenous melatonin on sleep: a meta-analysis. Sleep Med Rev. 2005 Feb. 9(1):41-50. [QxMD MEDLINE Link].
Buscemi N, Vandermeer B, Hooton N, Pandya R, Tjosvold L, Hartling L, et al. Efficacy and safety of exogenous melatonin for secondary sleep disorders and sleep disorders accompanying sleep restriction: meta-analysis. BMJ. 2006 Feb 18. 332(7538):385-93. [QxMD MEDLINE Link]. [Full Text].
Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010 Aug 16;8... Wade AG, Ford I, Crawford G, et al. Nightly treatment of primary insomnia with prolonged release melatonin for 6 months: a randomized placebo controlled trial on age and endogenous melatonin as predictors of efficacy and safety. BMC Med. 2010 Aug 16;8:51. Full text: http://www.biomedcentral.com/1741-7015/8/51.
Rondanelli M, Opizzi A, Monteferrario F, Antoniello N, Manni R, Klersy C. The effect of melatonin, magnesium, and zinc on primary insomnia in long-term care facility residents in Italy: a double-blind, placebo-controlled clinical trial. J Am Geriatr Soc. 2011 Jan. 59(1):82-90. [QxMD MEDLINE Link].
Bent S, Padula A, Moore D. Valerian for sleep: a systematic review and meta-analysis. Am J Med. Dec 2006. 119(12):1005-12.
Fernández-San-Martín MI, Masa-Font R, Palacios-Soler L, Sancho-Gómez P, Calbó-Caldentey C, Flores-Mateo G. Effectiveness of Valerian on insomnia: a meta-analysis of randomized placebo-controlled trials. Sleep Med. 2010 Jun. 11(6):505-11. [QxMD MEDLINE Link].
Taavoni S, Ekbatani N, Kashaniyan M, Haghani H. Effect of valerian on sleep quality in postmenopausal women: a randomized placebo-controlled clinical trial. Menopause. 2011 Sep. 18(9):951-5. [QxMD MEDLINE Link].
Meolie AL, Rosen C, Kristo D, Kohrman M, Gooneratne N, Aguillard RN, et al. Oral nonprescription treatment for insomnia: an evaluation of products with limited evidence. J Clin Sleep Med. 2005 Apr 15. 1(2):173-87. [QxMD MEDLINE Link].
Sun JL, Sung MS, Huang MY, Cheng GC, Lin CC. Effectiveness of acupressure for residents of long-term care facilities with insomnia: a randomized controlled trial. Int J Nurs Stud. 2010 Jul. 47(7):798-805. [QxMD MEDLINE Link].
Anderson, P. FDA Approves New Device for Insomnia. Medscape Medical News. Available at http://www.medscape.com/viewarticle/864509. June 8, 2016; Accessed: June 9, 2016.
Ancoli-Israel S, Martin JL. Insomnia and daytime napping in older adults. J Clin Sleep Med. 2006 Jul 15. 2(3):333-42. [QxMD MEDLINE Link].
Kryger M, Monjan A, Bliwise D, Ancoli-Israel S. Sleep, health, and aging. Bridging the gap between science and clinical practice. Geriatrics. 2004 Jan. 59(1):24-6, 29-30. [QxMD MEDLINE Link].
Liu L and Ancoli-Israel S. Insomnia in the Older Adult. Sleep Med Clin. 2006. 1(3):409-422.
Reid KJ, Baron KG, Lu B, Naylor E, Wolfe L, Zee PC. Aerobic exercise improves self-reported sleep and quality of life in older adults with insomnia. Sleep Med. 2010 Oct. 11(9):934-40. [QxMD MEDLINE Link]. [Full Text].
[Guideline] American Academy of Sleep Medicine. Five Things Physicians and Patients Should Question. Choosing Wisely. Available at http://www.aabb.org/pbm/Documents/Choosing-Wisely-Five-Things-Physicians-and-Patients-Should-Question.pdf. December 2, 2014; Accessed: August 1, 2016.
Mukherjee S, Patel SR, Kales SN, Ayas NT, Strohl KP, Gozal D, et al. An Official American Thoracic Society Statement: The Importance of Healthy Sleep. Recommendations and Future Priorities. Am J Respir Crit Care Med. 2015 Jun 15. 191 (12):1450-8. [QxMD MEDLINE Link].
Lowes, R. FDA OKs New Kind of Sleep Drug Suvorexant (Belsomra). Medscape Medical News. Available at http://www.medscape.com/viewarticle/829893. Accessed: August 16, 2014.
Brooks M. FDA Cuts Starting Dose of Eszopiclone (Lunesta) in Half. Medscape Medical News. May 15 2014. [Full Text].

Media Gallery

Theoretical model of the factors causing chronic insomnia. Chronic insomnia is believed to primarily occur in patients with predisposing or constitutional factors. These factors may cause the occasional night of poor sleep but not chronic insomnia. A precipitating factor, such as a major life event, causes the patient to have acute insomnia. If poor sleep habits or other perpetuating factors occur in the following weeks to months, chronic insomnia develops despite the removal of the precipitating factor. Adapted from Spielman AJ, Caruso LS, Glovinsky PB: A behavioral perspective on insomnia treatment. Psychiatr Clin North Am. 1987 Dec;10(4):541-53.
Mallampati airway scoring.
Diagnostic algorithm for major depression.
Diagnostic criteria for generalized anxiety disorder.
Sleep diary.
GABAA receptor subunit function(s).
GABAA receptor complex subunits and schematic representation of agonist binding sites.
Sleep-wake cycle.
The ascending arousal system. Adapted from Saper et al. Hypothalamic Regulation of Sleep and Circadian Rhythms. Nature 2005;437:1257-1263.
Ventrolateral pre-optic nucleus inhibitory projections to main components of the arousal system to promote sleep.
Schematic flip-flop switch model. Adapted from Saper C et al. Hypothalamic regulation of sleep and circadian rhythms. Nature 2005;437:1257-1263.
Epworth Sleepiness Scale.
Frequency of insomnia causes.

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Author

Jasvinder Chawla, MD, MBA Chief of Neurology, Hines Veterans Affairs Hospital; Professor of Neurology, Loyola University Medical Center

Jasvinder Chawla, MD, MBA is a member of the following medical societies: American Academy of Neurology, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American Medical Association

Disclosure: Nothing to disclose.

Coauthor(s)

Youngsook Park, MD Co-Director in SLEEP Lab, Hines Veterans Affairs Medical Center; Assistant Professor of Neurology, Loyola University, Chicago Stritch School of Medicine

Youngsook Park, MD is a member of the following medical societies: American Academy of Neurology, Willis-Ekbom Disease Foundation, American Academy of Sleep Medicine

Disclosure: Received none from Hines VA Hospital for none.

Erasmo A Passaro, MD, FAAN, FAES, FAASM, FACNS Director, Comprehensive Epilepsy Program/Clinical Neurophysiology Lab, Bayfront Health System, Florida Center for Neurology; Director, Epilepsy Surgery Program, Johns Hopkins All Children's Hospital

Erasmo A Passaro, MD, FAAN, FAES, FAASM, FACNS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association, American Society of Neuroimaging

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: UCB; Sunovion; Eisai, GWPharma.

Chief Editor

Selim R Benbadis, MD Professor, Director of Comprehensive Epilepsy Program, Departments of Neurology and Neurosurgery, Tampa General Hospital, University of South Florida Morsani College of Medicine

Selim R Benbadis, MD is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Clinical Neurophysiology Society, American Epilepsy Society, American Medical Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Bioserenity, Ceribell, Eisai, Jazz, LivaNova, Neurelis, Neuropace, SK life science, Sunovion, Takeda, UCB<br/>Serve(d) as a speaker or a member of a speakers bureau for: Aquestive, Bioserenity, Eisai, Jazz, LivaNova, Neurelis, SK life science, Stratus, Sunovion, UCB<br/>Received research grant from: Cerevel Therapeutics, Ovid Therapeutics, Neuropace, Greenwich Jazz, SK Life Science, Xenon Pharmaceuticals, UCB, Marinus, Neuroelectrics Corporation, Longboard, Janssen, Equilibre Biopharmaceuticals.

Acknowledgements

Carmel Armon, MD, MSc, MHS Professor of Neurology, Tufts University School of Medicine; Chief, Division of Neurology, Baystate Medical Center

Carmel Armon, MD, MSc, MHS is a member of the following medical societies: American Academy of Neurology, American Academy of Sleep Medicine, American Association of Neuromuscular and Electrodiagnostic Medicine, American Clinical Neurophysiology Society, American College of Physicians, American Epilepsy Society, American Medical Association, American Neurological Association, American Stroke Association, Massachusetts Medical Society, Movement Disorders Society, and Sigma Xi

Disclosure: Avanir Pharmaceuticals Consulting fee Consulting

Kendra Becker, MD, MPH Sleep Medicine Department, Kaiser Permanente Fontana Medical Center

Kendra Becker, MD, MPH is a member of the following medical societies: American Academy of Sleep Medicine, American College of Physicians, and American Medical Association