Medications to Treat Insomnia
Pharmacological therapy to treat insomnia may include over-the-counter sleep medications, antidepressants with sedative effects, benzodiazepines, and newer medicines (e.g., non-benzodiazepines). Some insomnia medications are used for a short period of time and some medications are indicated for longer use.
Over-the-counter Sleep Medications
Over-the-counter (OTC) sleep aids usually contain antihistamines, which are associated with drowsiness. Unfortunately, these medications also tend to cause side effects, such as decreased memory and concentration, dry mouth, morning sickness, blurred vision, extended sedation, and constipation. These drugs are generally not recommended for the treatment of insomnia that is severe enough to require attention of a physician. They should not be used to treat chronic insomnia, may provide only temporary relief, and can further disrupt sleep over the long term.
Many antidepressants have sedative side effects. These side effects may be utilized in patients with depression and insomnia. In fact, many widely used antidepressants, like Prozac, actually regulate sleep onset and duration for patients who take them. Some antidepressants can cause significant sedation in the morning and others may affect rapid eye movement sleep (REM) and disrupt sleep quality. Generally, these medications are used to treat depression that causes insomnia; drowsiness as a side effect is used to an advantage in helping with difficulty sleeping. See more on antidepressants.
Benzodiazepines also may be used to treat insomnia. There are several hypnotic drugs (commonly called sleeping pills) available. The primary difference among benzodiazepines is the length of effectiveness, or half life, of the medication in the body. Longer-acting benzodiazepines often result in carry-over morning sedation, and shorter-acting benzodiazepines cause a higher incidence of rebound insomnia after discontinuation. In some patients, these medications carry a risk for developing drug dependency with long-term use. Benzodiazepines can cause fatigue, dizziness, confusion, falls, and blurred vision, especially in older people. Operating a motor vehicle or heavy machinery while using this type of medication may be hazardous.
Newer drugs (called non-benzodiazepines), such as zaleplon (Sonata), zolpidem (Ambien, Ambien CR, Edluar, Zolpimist), eszopiclone (Lunesta), and zopiclone (Imovane), interact with benzodiazepine receptors on cells that induce sleep. These drugs have a rapid onset, result in a lower residual effect the next morning, and generally cause few mild side effects.
Side effects of these medications include the following:
- Constipation or diarrhea
- Dry mouth
Some patients experience more serious side effects while taking non-benzodiazepines. These side effects include allergic reactions, memory loss, and abnormal thoughts and behavior (e.g., performing various activities while unaware and not fully awake).
In November 2011, the U.S. Food and Drug Administration (FDA) approved the first medication to treat insomnia characterized by waking in the middle of the night and having difficulty falling back to sleep. This drug, called zolpidem tartrate sublingual tablets (Intermezzo) should not be used with other sleep aids or after consuming alcohol and should only be taken when at least 4 more hours of sleep are desired. Intermezzo can cause side effects that are similar to other non-benzodiazepines.
In January 2013, the FDA lowered the recommended bedtime doses of zolpidem. According to recent research, morning blood levels of the drug may be high enough to impair alertness in some people who take it. This risk is higher in those who take extended-release forms of the medication (Ambien CR and generic versions) and in women, who metabolize the drug more slowly than men. Talk to your health care provider - the lowest dose that controls your insomnia should be used. New dosing recommendations are 5 mg for immediate-release products and 6.25 mg for extended-release products.
The FDA approved a new type of insomnia drugsuvorexant (Belsomra), an orexin receptor antagonistin August 2014. This medication alters the effects of orexins, which are chemicals in the brain that help regulate the sleep-wake cycle and play a role in promoting wakefulness. Belsomra is available in 5, 10, 15, and 20 mg strengths. It can cause next-morning drowsiness and decreased alertness leading to impaired driving ability, so the smallest effect dose of the drug should be used.
Belsomra is a tablet that is taken once daily, within 30 minutes of going to bed and when at least 7 hours of sleep is desired. In clinical trials, people taking this drug fell asleep faster and spent less time awake than people who took a placebo. Side effects include drowsiness and performing complex tasks (e.g., preparing food, making phone calls) without being completely awake. This medication is classified as a controlled substance because it carries a risk for abuse and dependence.