Insomnia Medication Classes: An Overview
Cognitive behavioral therapy for insomnia (CBT-I) is the recommended first treatment for chronic insomnia in adults. Medicines are sometimes used as well. This overview lists the main classes, with examples and how the 2017 AASM pharmacologic guideline addressed them. It covers classes only, not doses, and is not advice to start, stop or change any medicine.
| Class | Examples (US) | How it works | Notes |
|---|---|---|---|
| Nonbenzodiazepine receptor agonists ("Z-drugs") | Zolpidem, eszopiclone, zaleplon | Enhance GABA, the brain's main calming signal, at the benzodiazepine receptor site | FDA boxed warning (2019) about complex sleep behaviors such as sleepwalking and sleep driving |
| Benzodiazepines | Temazepam, triazolam | Enhance GABA activity | Risk of dependence, next day sedation and falls; FDA boxed warning on abuse, dependence and withdrawal |
| Orexin receptor antagonists | Suvorexant, lemborexant, daridorexant | Block orexin, a brain signal that promotes wakefulness | Newer class; next day drowsiness possible; not for people with narcolepsy |
| Melatonin receptor agonist | Ramelteon | Acts on melatonin receptors | AASM suggested for sleep onset insomnia |
| Low dose doxepin | Doxepin (low dose formulation) | Blocks histamine H1 receptors | AASM suggested for sleep maintenance insomnia |
| Sedating antidepressants used off label | Trazodone | Several receptor actions including histamine and serotonin | AASM suggested not using trazodone for insomnia, citing weak evidence |
| Over the counter antihistamines | Diphenhydramine, doxylamine | Block histamine H1 receptors | AASM suggested against diphenhydramine; anticholinergic side effects, especially in older adults |
| Dietary supplements | Melatonin, valerian | Variable | AASM suggested against melatonin and valerian for chronic insomnia; supplements are not FDA approved drugs |
Notes
- The AASM recommendations were graded weak and based on limited evidence; individual choices depend on the person, other conditions and other medicines.
- Combining sleep medicines with alcohol, opioids or other sedatives is dangerous.
- Older adults are at higher risk of falls and confusion with many sleep medicines.
Frequently asked questions
Should I take sleeping pills for insomnia?
CBT-I is the recommended first line treatment for chronic insomnia and has longer lasting benefits. A clinician may add medicine in some cases, usually short term, after weighing risks.
Is melatonin good for insomnia?
The 2017 AASM guideline suggested against melatonin for chronic insomnia in adults because of weak evidence. Melatonin has better evidence for some circadian rhythm problems.
Are over the counter sleep aids safe?
Most contain sedating antihistamines, which can cause next day grogginess, confusion, constipation and urinary problems, particularly in older adults. Ask a pharmacist or clinician.
Sources
More reference tables
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