Insomnia: Medical Treatments
There are four types of drugs that have been approved by the Food and Drug Administration (FDA) to help treat insomnia: benzodiazepines, nonbenzodiazepines, melatonin receptor agonist, and antidepressants.
Benzodiazepines are a common class of drugs used to treat insomnia. However, it is generally discouraged to prescribe a benzodiazepine if the patient is taking an opioid(s) for the moderate to severe cancer or chronic noncancer pain. Benzodiazepines are not generally used to treat insomnia in patients with chronic pain, especially when safer alternatives are available.
Benzodiazepines work on the central nervous system (CNS, brain) to induce feelings of relaxation, sedation, euphoria, and muscle relaxation. These medications are used with caution since they can be habit-forming, and should not be combined with alcohol, opioids, or other CNS depressants as this increases the risk for toxicity and overdose. Examples of benzodiazepines include estazolam and flurazepam. These medications are indicated for people who have difficulty failing asleep, frequent awakenings, and early morning awakening.
Other benzodiazepines, like temazepam (Restoril, generics) and triazolam (Halcion, generics), are designed for the short-term treatment of insomnia. Triazolam is believed to cause rebound anxiety, and may not be an appropriate choice for certain patients.
All benzodiazepines should be used in caution in elderly patients due to increased risk of falls. Tolerance to the effect may develop after 1 month of therapy.
Generally considered a first choice for medical treatment of insomnia, nonbenzodiazepines are closely related to benzodiazepines, but have only the sedative effects (and not the hypnotic, anti-anxiety, or muscle relaxant effects).
The best known product in this category is zolpidem (Ambien). Other formulations of zolpidem include Edluar and Intermezzo (long-acting tablet), and Zolpimist (oral spray).
- Zolpidem is designed to treat insomnia in the short term by aiding patients to fall asleep.
- Zolpidem CR, also known as Ambien CR, helps with inducing sleep onset and maintenance (staying asleep and getting a full rest).
- Intermezzo is used to treat patients who are able to fall asleep, yet awake in the middle of the night and can’t fall back asleep. Patients must have at least 4 hours of sleep before awakening if they are going to use Intermezzo.
Ambien CR is a useful medication for treating insomnia because it is a controlled-release form. This will help prevent patients from waking up after they have fallen asleep.
Zolpidem is associated with certain side effects such as drowsiness, amnesia, dizziness, headache, wakefulness after sleep onset, and gastrointestinal effects. Well publicized, but rare side effects of these medicines, include sleep eating, sleep walking, or driving while asleep. This led the FDA to ask manufacturers provide a warning to inform patients of these risks before taking it and to adjust the dosing of zolpidem differently for men and women.
Eszopiclone, better known as Lunesta, is commonly prescribed to treat insomnia. Due to a recent labeling change, all patients should start at a lower dose lower (at 1 mg) to reduce the onset of next-day memory impairment and impaired driving skills. Eszopiclone is prescribed to prevent awakening in the early morning hours. Eszopiclone, like most drugs for insomnia, is not recommended for long-term use.
Eszopiclone is known to cause daytime sleepiness, which can be very dangerous when patients are operating machinery or a motor vehicle. Eszopiclone also causes unpleasant or metallic taste as well as other side effects such as headaches, chest pain, cold-like symptoms, drowsiness, pain, dry mouth, lightheadedness, dizziness, gastrointestinal effects, decreased sexual appetite, heartburn, and painful menstruations in women.
Another nonbenzodiazepine that is similar to eszopiclone is zaleplon (Sonata). Zalepon starts working a little faster than eszopiclone; at 30 minutes instead of an hour, so it is very useful for helping patients fall alseep. Zaleplon isn’t effective for reducing nighttime awakenings or increasing total sleep time because it has a very short half-life. Unlike other medications, zaleplon doesn’t have significant residual effects, which makes it a lot safer for people who need to commute frequently or operate dangerous machinery. Side effects of zaleplon include headaches, dizziness, and somnolence.
Melatonin Receptor Agonist
This type of drug class works by activating the melatonin receptor in the brain. The receptor is responsible for binding melatonin, a hormone known to help regulate the circadian rhythm, or sleep cycle. Ramelteon (Rozerem) is an example of a melatonin receptor agonist that will help patients fall asleep, especially if they are suffering from chronic or transient insomnia. Like zaleplon, this drug is not as helpful for reducing nighttime awakenings. Side effects commonly associated with the drug are headache, dizziness, and somnolence.
It was discovered that one side effect of tricyclic antidepressants was sedation. Thus, a low-dose form of trazodone, mirtazapine, doxepin, and/or amitriptyline have become an option for patients who suffer from depression and insomnia. There are certain advantages and disadvantages to what type of antidepressant to use—and only doxepin is FDA-approved for insomnia—so weight the risks and benefits carefully before prescribing.