CLINICAL PRINTABLE
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A one-page Insomnia clinical reference is on the way.
1 · Recognition / Alarm Features
- Insomnia disorder: difficulty initiating or maintaining sleep, or early morning awakening, with associated daytime impairment (fatigue, cognitive difficulty, mood disturbance), occurring ≥3 nights/week for ≥3 months. Acute insomnia: <3 months, often triggered by a stressor.
- Characterize the insomnia: sleep onset insomnia (difficulty falling asleep — anxiety, poor sleep hygiene, delayed sleep phase), sleep maintenance insomnia (frequent awakenings — pain, nocturia, sleep apnea, depression), early morning awakening (waking 2+ hours early — depression, advanced sleep phase, alcohol).
- Screen for obstructive sleep apnea (OSA): snoring, witnessed apneas, excessive daytime sleepiness, obesity, large neck circumference. OSA causes fragmented sleep and insomnia. STOP-BANG questionnaire. Polysomnography or home sleep apnea test. Treating OSA often resolves insomnia.
- Comorbid conditions causing insomnia: depression (early morning awakening), anxiety (sleep onset insomnia), chronic pain, GERD, nocturia (BPH, heart failure, diabetes), restless legs syndrome (RLS), periodic limb movement disorder (PLMD), hyperthyroidism.
- Medication causes: stimulants (caffeine, pseudoephedrine, methylphenidate), SSRIs/SNRIs (activating), beta-blockers (nightmares, fragmented sleep), corticosteroids, diuretics (nocturia), alcohol (rebound insomnia in second half of night), nicotine.
2 · Differential / Secondary Causes
Obstructive sleep apnea (OSA)
Fragmented sleep, excessive daytime sleepiness, snoring, witnessed apneas. CPAP is definitive treatment. Treating OSA often resolves comorbid insomnia. Do not prescribe sedative-hypnotics without screening for OSA — they can worsen upper airway obstruction.
Restless legs syndrome (RLS)
Uncomfortable urge to move legs, worse at rest and in the evening, relieved by movement. Causes sleep onset insomnia. Check ferritin and transferrin saturation — iron deficiency is a common cause; consider iron treatment when guideline thresholds are met and reassess response. Dopamine agonists (pramipexole, ropinirole) or gabapentin for moderate-to-severe RLS.
Circadian rhythm disorder
Delayed sleep phase (night owls — can't fall asleep until late, difficulty waking early): light therapy in the morning, melatonin in the evening. Advanced sleep phase (early birds — fall asleep early, wake early): light therapy in the evening.
Psychophysiological insomnia
Conditioned arousal — the bed becomes associated with wakefulness and frustration. Perpetuating factor in chronic insomnia. CBT-I (stimulus control, sleep restriction) is the most effective treatment.
3 · Treatment Pathway
CBT-I — first-line treatment
Cognitive behavioral therapy for insomnia (CBT-I) is more effective than medications and has durable effects. Components: sleep restriction (limit time in bed to actual sleep time), stimulus control (bed only for sleep/sex), sleep hygiene education, cognitive restructuring, relaxation techniques. Digital CBT-I (Sleepio, Somryst) is effective when in-person therapy is unavailable.
Sleep hygiene
Consistent sleep/wake schedule (including weekends). Avoid caffeine after noon. Avoid alcohol within 3 hours of bedtime (causes rebound insomnia). Avoid screens 1 hour before bed (blue light suppresses melatonin). Cool, dark, quiet bedroom. Avoid naps >20 minutes or after 3 PM. Exercise regularly (not within 2–3 hours of bedtime).
Melatonin
Low-dose melatonin (0.5–3 mg) 30–60 minutes before desired sleep time. Most effective for circadian rhythm disorders (jet lag, shift work, delayed sleep phase) and sleep onset insomnia. Less effective for sleep maintenance insomnia. Safe, non-habit-forming. OTC doses (5–10 mg) are higher than needed — start low.
Sedative-hypnotics — short-term use
Indicated for short-term (2–4 weeks) acute insomnia when CBT-I is not immediately available. Non-benzodiazepine receptor agonists (Z-drugs): zolpidem, eszopiclone, zaleplon. Risks: next-day sedation, complex sleep behaviors (sleepwalking, sleep-driving), dependence, rebound insomnia on discontinuation. Avoid in elderly (Beers Criteria), patients with OSA, and substance use history.
Other pharmacologic options
Doxepin (low-dose, 3–6 mg): FDA-approved for sleep maintenance insomnia. Suvorexant/lemborexant (orexin receptor antagonists): effective for sleep onset and maintenance, lower abuse potential than Z-drugs. Trazodone (off-label, 25–100 mg): commonly used, sedating, useful when comorbid depression. Avoid diphenhydramine (Benadryl) — tolerance develops within days, anticholinergic effects, cognitive impairment.
4 · Expected Response
- CBT-I: improvement in sleep onset latency and wake after sleep onset within 4–8 weeks. Effects are durable — superior to medications at 6–12 months.
- Z-drugs: onset within 30 minutes. Effective for 2–4 weeks. Rebound insomnia on discontinuation — taper rather than stopping abruptly.
- Treating the underlying cause (OSA, RLS, depression, pain): insomnia often resolves when the primary condition is adequately treated.
5 · Escalation
- Suspected OSA (snoring, witnessed apneas, excessive daytime sleepiness): home sleep apnea test or polysomnography. Do not prescribe sedative-hypnotics without screening for OSA.
- Refractory insomnia not responding to CBT-I and pharmacotherapy: sleep medicine referral for polysomnography to exclude OSA, PLMD, or other sleep disorders.
- Complex sleep behaviors on Z-drugs (sleepwalking, sleep-driving, sleep-eating): discontinue immediately. FDA black box warning.
Apply It · Change One Detail
APPLY IT
A 45-year-old woman with 6 months of difficulty falling asleep and staying asleep, with daytime fatigue. She drinks 2 glasses of wine nightly to 'help her sleep.' Screen for OSA (negative), depression (PHQ-9 = 6, mild), and anxiety (GAD-7 = 8, moderate). Alcohol causes rebound insomnia in the second half of the night — this is a major perpetuating factor. Counsel on alcohol reduction, refer to CBT-I, and address the anxiety. Avoid prescribing a sedative-hypnotic without first addressing the alcohol and behavioral factors.
CHANGE ONE DETAIL
Change one detail — the same patient also reports snoring, witnessed apneas, and excessive daytime sleepiness. Now OSA is the primary diagnosis. Order a home sleep apnea test. Do not prescribe zolpidem — sedative-hypnotics can worsen upper airway obstruction in OSA. CPAP is the treatment. Insomnia often resolves with effective OSA treatment.
Bottom Line
CBT-I is more effective than medications for chronic insomnia and has durable effects. Treat the underlying cause first — OSA, depression, pain, and alcohol are common perpetuating factors. Avoid sedative-hypnotics in patients with OSA, elderly patients, and those with substance use history.
EVIDENCE & REFERENCES
- Qaseem A, et al. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Ann Intern Med. 2016;165(2):125-133. doi:10.7326/M15-2175
- Riemann D, et al. European guideline for the diagnosis and treatment of insomnia. J Sleep Res. 2017;26(6):675-700. doi:10.1111/jsr.12594
- Mitchell MD, et al. Comparative effectiveness of cognitive behavioral therapy for insomnia: a systematic review. BMC Fam Pract. 2012;13:40. doi:10.1186/1471-2296-13-40