Cognitive behavioral therapy (CBT) is usually the first-line treatment for chronic insomnia. Doctors sometimes prescribe medications to help manage this sleep disorder. Medications for chronic insomnia may be effective, but they are not typically recommended for long-term use due to their potential side effects and risk of dependence.
According to the American Psychiatric Association, about one-third of adults in the United States occasionally experience insomnia. This is a sleep disorder characterized by difficulty falling or staying asleep. When a person experiences these difficulties over an extended period of time, it becomes chronic insomnia.
People can often manage occasional bouts of insomnia with lifestyle changes such as trying relaxation techniques, exercising, and improving their sleep hygiene. However, people with chronic insomnia may need to visit a doctor for treatment.
A healthcare professional who treats sleep disorders can determine if an underlying condition — such as hypothyroidism, obstructive sleep apnea, or restless legs syndrome — could be causing the person’s sleep problems. For some people, insomnia does not appear to have an underlying cause.
The first line of treatment for chronic insomnia is an approach known as CBT for insomnia (CBTi). A mental health professional leads this multifaceted approach, which includes the following components:
- cognitive therapy, which helps people identify, address, and correct negative or inaccurate thoughts and behaviors
- behavioral interventions, which address problematic habits and help people develop healthy sleep habits through relaxation training, stimulus control, and sleep restriction
- sleep hygiene education, which includes making lifestyle changes such as limiting caffeine intake and avoiding screens close to bedtime
Somryst is a new, Food and Drug Administration (FDA)-approved prescription treatment that combines CBTi with an app-based delivery platform. The app takes users through a series of lessons and exercises to encourage sleep.
Other recommended treatments for insomnia include relaxation techniques and exercise.
Some people use medications alongside CBTi. Most medications only have approval for short-term use.
Medications can help some people with chronic insomnia. However, it is important to talk with a doctor before taking a sleep medication. These medications may have side effects, including drowsiness and dizziness. People should only take them before bed when they have at least 7 hours to sleep.
Medications for treating insomnia fall into one of several categories. The sections below look at these categories in more detail.
Benzodiazepine receptor agonists
Benzodiazepine receptor agonists (BZRAs) target a specific part of the brain and may increase a neurotransmitter called gamma-aminobutyric acid (GABA). GABA is a chemical that inhibits, or slows, the brain’s functions. The brain naturally releases GABA to promote sleep at nighttime.
BZRAs include both benzodiazepine hypnotics and nonbenzodiazepine BZRAs.
For decades, benzodiazepine hypnotics were the only drugs with FDA approval for treating insomnia. These drugs can increase the risk of falls, vehicle accidents, memory problems, and daytime sedation, especially among older adults. They are also likely to lead to dependence.
Some studies suggest that their benefits decline after 4 weeks of use.
Examples of BZRAs that are FDA-approved for treating insomnia include:
- estazolam (ProSom)
- flurazepam (Dalmane)
- quazepam (Doral)
- temazepam (Restoril)
- triazolam (Halcion)
In the 1990s, nonbenzodiazepine BZRAs entered the market. They are now widely prescribed. These medications help reduce some of the side effects common with benzodiazepines.
However, nonbenzodiazepine BZRAs still carry side effects, including dizziness and drowsiness. For this reason, a person should not operate a vehicle within 8 hours of taking this type of medication.
Some people who take nonbenzodiazepine BZRAs experience “complex sleep behaviors.” These include sleep-walking, sleep-driving, and participating in other activities while not fully awake. This can result in serious injury. A person should stop taking their medication immediately if they experience any complex sleep behaviors.
In addition, nonbenzodiazepine BZRAs are classified as Schedule IV controlled substances. This means that they can lead to misuse, dependence, and withdrawal.
Examples of nonbenzodiazepine BZRA oral medications for the short-term treatment of insomnia include:
- Zolpidem (Ambien): Doctors prescribe this medication for insomnia that is characterized by difficulties falling asleep. The prescribing label recommends a starting dose of 5 milligrams (mg) for females and 5 mg or 10 mg for males. People should take it right before bedtime. The medication is also available in an extended-release tablet under the brand name Ambien CR.
- Eszopiclone (Lunesta): This medication has been shown in
clinical trialsto decrease the time it takes to fall asleep and to improve the ability to stay asleep. The recommended starting dose of Lunesta is 1 mg, taken immediately before bedtime. A doctor can increase the dose to a maximum of 3 mg.
- Zaleplon (Sonata): Studies suggest that this medication decreases the time it takes to fall asleep. It has not been shown to increase total sleep time or decrease the number of awakenings. The recommended dose for most adults is 10 mg, but older adults and people with low body weights may only need 5 mg.
Histamine receptor agonists
Histamine is a neurotransmitter that plays an important role in regulating the sleep-wake cycle. Experts believe that stimulation of the histamine receptor aids in the process of waking up.
Doxepin (Silenor) is a tricyclic antidepressant medication that acts on the histamine receptor. It is a histamine receptor agonist, which means that it works by binding to the histamine receptors to block the arousal pathway. It is FDA-approved to treat insomnia that involves difficulties with the ability to stay asleep.
Silenor is an oral tablet. The recommended dose is 6 mg for adults and 3 mg for older adults, taken within 30 minutes of bedtime.
Some studies indicate that Silenor is well-tolerated and does not cause memory impairment or next-day “hangover” effects. In higher amounts, however, Silenor can cause unusual thinking, behavioral changes, hallucinations, and complex sleep behaviors.
Research suggests that the medication is not habit-forming.
Melatonin receptor agonists
Melatonin is a hormone that regulates the sleep-wake cycle. Normally, melatonin levels are low during the day and gradually rise in the evening before bedtime. Melatonin levels decline again by the morning.
Ramelteon (Rozerem) is a melatonin receptor agonist that is FDA-approved for the treatment of insomnia that is characterized by difficulty with sleep onset. Research suggests that ramelteon does not have misuse potential, and the drug is not classed as a controlled substance.
The most common side effects of ramelteon are drowsiness, dizziness, and fatigue. People should take this oral tablet at a dose of 8 mg about 30 minutes before bedtime.
Dual orexin receptor antagonists
Orexin is a neuropeptide that promotes wakefulness to impact the sleep-wake cycle. Dual orexin receptor antagonists (DORAs) are newer medications that limit the effect of orexin to decrease wakefulness.
No studies have directly compared DORAs with other drugs marketed for insomnia, though they are thought to be safer than prescription BZRAs and may be less likely to cause drowsiness the next day and affect the ability to drive vehicles.
Controlled, long-term studies have not evaluated the safety of DORAs. Side effects of these drugs may include dizziness and impaired alertness and motor coordination the next day. Rarely, these medications can cause complex sleep behaviors.
Two DORAs currently have FDA approval to treat insomnia, both of which come as oral tablets. They are Suvorexant (Belsomra) and Lemborexant (Dayvigo).
In 2014, the FDA approved Belsomra to treat insomnia. Placebo-controlled
In 2019, the FDA approved Dayvigo for treating insomnia. In a placebo-controlled clinical trial, Dayvigo significantly improved sleep efficiency, latency to persistent sleep, and sleep onset in people with insomnia. It also minimized sleepiness the following day. However, the medication can cause a worsening of depression or suicidal thinking.
The recommended dose of Dayvigo is a 50-mg tablet, taken immediately before bed.
Both drugs are classed as Schedule IV drugs, but they have very low misuse potential, and there is no evidence of physical dependence.
OTC medications and supplements
Some people find that OTC antihistamines (diphenhydramine and doxylamine) and the supplement melatonin promote sleep. The sections below look at these options in more detail.
A person should always talk with a doctor before starting any new OTC medication or supplement.
Diphenhydramine (ZzzQuil) and doxylamine (Unisom) are antihistamines that cause drowsiness. They are available over the counter in liquid and tablet form at most drugstores. The recommended dose for insomnia is 50 mg for the tablet and 30 milliliters for the liquid formulation.
It is possible to quickly build up a tolerance to diphenhydramine, which means that it becomes less effective over time. Long-term use of diphenhydramine has also been
Melatonin is a hormone that the body naturally produces. Some people call it “the sleep hormone” because levels increase in the evening as it gets dark outside to promote sleep. Melatonin is also available as a supplement without a prescription.
Although there is no official recommendation, a typical dose of melatonin is 1–5 mg, taken 30 minutes before bedtime. It is generally recommended to start at a lower dose and increase it until effective.
Research indicates that taking melatonin before bed may speed up the time it takes to fall asleep and may be particularly helpful for shift workers who have difficulty falling asleep. However, more research is needed to support the use of melatonin at bedtime for treating insomnia.
Side effects are generally mild and may include dizziness, headaches, and nausea.
Other prescription medications used for sleep
To treat insomnia, a doctor may prescribe one of several other off-label medications that could help influence sleep-wake cycles. Alternatively, they may recommend one of these medications if a person has another condition that the drug has FDA approval to treat, with the goal of also managing insomnia.
However, there is limited evidence to suggest that these drugs are effective insomnia treatments.
Some examples include:
- antidepressants, such as mirtazapine and amitriptyline
- antipsychotics, such as quetiapine
- antianxiety medications, such as alprazolam and clonazepam
- antihypertensives, such as clonidine
Relaxation strategies and mindfulness techniques, such as meditation and yoga, are major components of CBTi.
A meta-analysis of 19 studies also indicates that yoga can be beneficial for women with sleep problems.
Exercise is another method that may help with chronic insomnia.
Exercise may also improve stress and anxiety, which may lead to better sleep.
One way to manage sleep disorders involves building healthy habits to help with falling and staying asleep. This is called sleep hygiene, and it includes tips and tricks such as:
- avoiding caffeine
- avoiding the use of electronic devices close to bedtime
- going to sleep and waking up at about the same time every day
- making sure that the bedroom is cool, dark, and quiet
- using the bed only for sleep and sex
- limiting napping
- trying a weighted blanket
The first line of treatment for insomnia is an approach called CBTi, which includes cognitive therapy, behavioral therapy, and sleep hygiene education. Exercise and relaxation techniques have also been shown to improve sleep.
A healthcare professional may also recommend sleep medications. However, keep in mind that most medications for insomnia can have side effects, including daytime sleepiness, sleep-walking, and dizziness. Some can also be habit-forming. It is important to discuss the risks and benefits of sleep medications with a doctor.