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An in-depth report on the causes, diagnosis, treatment, and prevention of insomnia.


What is Insomnia?

Insomnia can be a short-term or long-term condition, but it always involves problems with falling asleep or staying asleep. Short-term (acute) insomnia can be caused by illness, stress, travel, or environmental factors. Long-term (chronic) insomnia may be due to underlying psychological or physical conditions.

Who is at Risk?

Anyone can get insomnia, but it is generally more common in women than in men. Older people are particularly at risk for insomnia.

Diagnosing Insomnia


  • How long does it take for you to fall asleep at night?
  • How many times during the night do you wake up?
  • Do you experience daytime fatigue?
  • What medications do you take (including prescription drugs, over-the-counter drugs, and herbs or supplements)?
  • Do you drink alcohol or smoke?


Treating Insomnia

  • Sleep hygiene is the most important step for controlling insomnia. These simple self-help measures include establishing a regular bedtime routine, regulating mealtimes and fluid consumption, and limiting caffeine consumption.
  • Cognitive behavioral therapy can help treat chronic insomnia in people of all ages. It includes various approaches for establishing new sleep behaviors and for helping people relax and sleep well.
  • If self-help or behavioral therapies do not solve the problem, a doctor may prescribe medications for use on a short-term basis.

Non-benzodiazepine sedative hypnotics are usually the preferred type of drugs. They include zolpidem (Ambien, generic), zaleplon (Sonata, generic), and eszopiclone (Lunesta, generic). Newer types of sedative hypnotics include ramelteon (Rozerem, generic) and suvorexant (Belsomra).

All sedative hypnotics can cause side effects, so make sure that your doctor explains the risks for these drugs and the precautions you need to take.


Insomnia comes from the Latin words for "no sleep." Insomnia is characterized by any of the following:

  • Difficulty falling asleep
  • Difficulty staying asleep
  • Waking up too early
  • Poor quality ("non-restorative") sleep

Insomnia may be primary or secondary:

  • Primary insomnia means that the inability to sleep occurs by itself and is not caused by other health problems.
  • Comorbid insomnia occurs together with other health conditions that interfere with sleep. It is also called "secondary insomnia", although it is unclear whether those conditions caused insomnia.

Duration of Insomnia

Insomnia is often categorized by how long it lasts:

  • Transient insomnia lasts for a few days.
  • Short-term (acute) insomnia lasts for several weeks.
  • Long-term (chronic) insomnia lasts for a month or longer.

Related Disorders


  • Delayed sleep-phase syndrome refers to a pattern of falling asleep very late at night or in the early morning hours, and having difficulty waking up in the morning. This syndrome is more likely to occur in adolescents.
  • Advanced sleep-phase syndrome refers to a pattern of falling asleep early in the evening (6 to 9 p.m.), waking early in the morning (3 to 5 a.m.), and being unable to fall back asleep. This syndrome tends to develop in older people.

Healthy Sleep

In studies of human sleep behavior, subjects spend about one-third of their time asleep, suggesting that most people need about 8 hours of sleep each day. Individual adults differ in the amount of sleep they need to feel well-rested. Infants may sleep as many as 16 hours a day.



  • Daytime activity and nighttime rest.
  • A natural peak in sleepiness at mid-day, the traditional siesta time.


  • The monthly menstrual cycle in women can shift the pattern.
  • Light signals coming through the eyes reset the circadian cycles each day, so changes in season or various exposures to light and dark can unsettle the pattern. Sunlight is an important regulator of circadian rhythms. People who are blind often have trouble falling asleep and waking up at "normal" times because they are missing the normal light cues.

There are significant variations in the time of the day that people prefer to go to sleep and wake up. This preference is also called morningness or eveningness. According to their sleep habits, people fall into two different chronotypes: the morning type, also called "larks", and the evening type, also called "owls". The morning type prefers to go to sleep and wake up early, and performs better in the first part of the day, while the evening type has an opposite pattern of activity and sleep. Some evidence indicates that sleep habits may be associated with variations in the CLOCK gene, one of the most important regulators of the circadian rhythm. This would suggest that morningness and eveningness have a genetic component.

The Response in the Brain to Light Signals


  • Light signals travel to a tiny cluster of nerves in the hypothalamus in the center of the brain, the body's master clock, which is called the suprachiasmatic nucleus (SCN).

Sleep Cycles

Sleep consists of REM and Non-REM sleep, two distinct states that alternate in cycles and reflect differing levels of brain nerve cell activity.

Non-Rapid Eye Movement (Non-REM) Sleep:

Non-REM (or NREM) sleep is also termed quiet sleep. Non-REM is divided into three stages of progression:

  • N1 (light sleep)
  • N2 (so-called true sleep)
  • N3 (deep "slow-wave" or delta sleep)

With each descending stage, awakening becomes more difficult. It is not known what governs NREM sleep in the brain. A balance between certain hormones, particularly growth and stress hormones, may be important for deep sleep.

Rapid Eye Movement (REM) Sleep:

During REM sleep the brain is highly active. This stage is called active sleep in babies. Most vivid dreams occur in REM sleep. In REM sleep, brain activity is comparable to that in waking, but the muscles are virtually immobilized, which prevents people from acting out their dreams. Except for muscles associated with vital organs like the lungs (the diaphragm) and heart, the only muscles not immobilized during REM are the eye muscles. REM sleep may be critical for learning and for day-to-day mood regulation. When people are sleep-deprived, their brains must work harder than when they are well-rested.

The REM/Non-REM Cycle:



Causes of Temporary Insomnia

A reaction to change or stress is a common cause of short-term (several weeks) and transient (several days) insomnia. This condition is sometimes referred to as adjustment sleep disorder.

The trigger could be a major or traumatic event such as:

  • An acute illness
  • Injury or surgery
  • The loss of a loved one
  • Job loss

Temporary insomnia can also develop due to a relatively minor situational event, including:

  • Extremes in weather
  • Stress about an exam
  • Trouble at work
  • Travel, particularly across time zones

In most cases, normal sleep almost always returns when the condition resolves, or when the person recovers from the event or becomes used to the new situation. Treatment is needed if sleepiness interferes with functioning or if it continues for more than a few weeks. Individual responses to stress vary. Some people never experience insomnia, even during very stressful situations while others may suffer from insomnia in response to very mild stressors.

Female Hormonal Fluctuations

Fluctuations in female hormones play a major role in insomnia in women over their lifetimes. This temporary insomnia may occur during:

  • Menstruation. Progesterone promotes sleep. Levels of this hormone plunge during menstruation, causing insomnia. When progesterone levels rise during ovulation, women may become sleepier than usual.
  • Menopause. Insomnia can be a major problem during the transition to menopause (perimenopause), when hormone levels are fluctuating intensely. In addition, hot flashes and night sweats can disrupt sleep and cause sudden and frequent awakening.

Jet Lag


Effect of Light and Other Environmental Disruptions


  • Insufficient Light during the Day. Insufficient exposure to light during the day, as occurs in some disabled older people who rarely venture outside, may also be linked with sleep disturbances.

Other Causes of Temporary Insomnia


Caffeine is a stimulant, which can interfere with falling asleep.



Partner's Sleep Habits

A partner's sleep habits, including snoring, can impair one's own sleep.



Causes of Chronic Insomnia

Sleep problems seem to run in families. Many people with chronic insomnia have a family history of insomnia, with the mother being the most commonly affected family member. Because there are so many factors involved in insomnia, a genetic component is difficult to define. However, recent studies indicate that several genes are associated with the presence of chronic insomnia.

Anxiety, Depression, and Other Mental Health Disorders


  • Anxiety
  • Depression
  • Bipolar disorder
  • Attention-deficit hyperactivity disorder
  • Post-traumatic stress disorder

Insomnia may also be the cause of emotional and mental health problems, such as depression and anxiety. It is often unclear which condition has triggered the other, or if the two conditions have a common source.

Psychophysiologic Insomnia


Psychophysiologic insomnia occurs when temporary insomnia disrupts your sleep patterns:

  • You begin to associate the bed not with rest and relaxation, but with a struggle to sleep. A pattern of sleep failure emerges.
  • Over time, going to bed becomes a source of anxiety. You focus on your inability to sleep, the consequences of sleep loss, and the lack of mental control. This makes falling asleep even more difficult.

Medical Conditions and Their Treatments

Among the many medical problems that can cause chronic insomnia are allergies, benign prostatic hyperplasia (BPH), arthritis, gastroesophageal reflux disease (GERD), asthma, chronic obstructive pulmonary disorder (COPD), rheumatologic conditions, Alzheimer disease, Parkinson disease, hyperthyroidism, epilepsy, and fibromyalgia. Other types of sleep disorders, such as restless legs syndrome and sleep apnea, can cause insomnia. Many people with chronic pain sleep poorly.

Among the many medications that can cause insomnia are antidepressants (especially bupropion), beta-blockers, and beta-agonists.

Substance Abuse

Substance abuse can cause chronic insomnia. This is true for both stimulants such as cocaine and sedatives such as alcohol. One or two alcoholic drinks may help reduce stress and initiate sleep. However, excessive alcohol use tends to fragment sleep and cause wakefulness a few hours later. It also increases the risk for other sleep disorders, including sleep apnea and restless legs syndrome. People who are alcohol-dependent often suffer insomnia during withdrawal and, in some cases, for several years during recovery.

Risk Factors

More than one-quarter of all Americans experience short-term (acute) insomnia at some point during a year, and nearly 10% have long-term (chronic) insomnia.


Overall, insomnia is more common in women than men, although men are not immune to insomnia. Sleep efficiency deteriorates equally in men and women as they get older.

Hormonal fluctuations that occur during menstruation, pregnancy, and menopause put women at higher risk for insomnia. Women are also more likely than men to suffer from anxiety and depressive disorders, which can cause insomnia.



Older people are also more likely than younger people to have medical conditions that cause pain or nighttime distress. These conditions include arthritis, gastrointestinal distress, frequent urination, lung disease, and heart conditions. Neurologic conditions, such as Parkinson disease and Alzheimer disease, can also affect sleep patterns. Consequences of poor sleep in older people include a higher risk of falling.

Shift Work


Night-shift workers are at risk for falling asleep on the job at least once a week, implying that their internal clocks do not fully adjust to unusual work times. They are also at much higher risk than other workers for automobile accidents due to their drowsiness and may also have a higher overall risk for health problems.


Insomnia itself is not life-threatening, but it can increase the risk for accidents, psychiatric problems, and certain medical conditions. It can also affect school and work performance, and significantly interfere with quality of life. Lack of sleep can cause weight gain and lead to obesity.

Increased Risk of Accidents


Quality of Life


Thinking and Performance

Insomnia makes it harder to concentrate and perform tasks. Deep sleep deprivation reduces concentration and impairs the brain's ability to process information.

Mood Disorders



Obesity and Weight Gain

Lack of sleep causes hormonal, metabolic, and brain activity changes that affect weight and appetite regulation. Research increasingly suggests that people who are sleep-deprived are more likely to have problems with weight gain and obesity, which can increase the risk for other health conditions, such as heart disease and diabetes.

Heart Health

Evidence suggests that chronic insomnia may moderately increase the risk for heart disease, heart attack, and heart failure. In men, insomnia may possibly increase the chance of death from cardiovascular disease. Research continues on the relationship between insomnia and the chronic inflammation associated with heart disorders.


Sleep Questionnaires

A number of questionnaires are available for determining whether a person has insomnia or other sleep disorders. For example, the doctor may ask:

  • How would you describe your sleep problem?
  • How long have you had the sleep problem?
  • How long does it take you to fall asleep?
  • How many times a week does it occur?
  • How restful is your sleep?
  • How does insomnia affect daytime functioning?
  • How much alcohol is consumed per day?
  • What stresses or emotional factors may be present?
  • Have you experienced any significant life changes?
  • Is there is a bed partner? Is this person's behavior distressing or disturbing?
  • Are you a shift worker?

Sleep Diary

Keeping a sleep diary is a helpful diagnostic tool. Every day for 2 weeks, record all sleep-related information (including responses to questions listed above). Other information should include the time you went to bed, time spent falling asleep, number of nocturnal awakenings, and rising time. The times that caffeine or alcohol are ingested are also frequently included in the diary. Your bed partner's observations of your sleep behavior can also help.

Measuring Sleepiness

The Epworth Sleepiness Scale is a questionnaire used to measure sleepiness by determining the likelihood of falling asleep in various types of situations.


Actigraphy uses a portable device with a sensor to monitor movement. Actigraphy may be used in some situations to help give a doctor a better picture of a person's sleep pattern. It cannot, however, determine the severity of sleep problems. Most people with insomnia are diagnosed and treated without this test. However, actigraphy may help identify insomnia in some people.

Sleep Disorders Centers



  • Insomnia due to psychologic disorders
  • Sleeping problems due to substance abuse
  • Severe restless legs syndrome
  • Persistent daytime sleepiness

Most sleep disorders centers perform an in-depth analysis, which includes polysomnography.

Polysomnography is the technical term for an overnight sleep study that involves recording brain waves and other sleep-related activity. Its primary role is in diagnosing obstructive sleep apnea, restless leg syndrome/periodic limb movement disorder, or other abnormal sleep behaviors called parasomnias, such as nightmares, sleepwalking, and acting out dreams. If obstructive sleep apnea is the most likely problem, a sleep device called a home sleep test may be provided for you to sleep within your home.




Behavioral Therapy

Various approaches are available to help people learn how to relax and sleep well. Although medications can help people with insomnia to sleep, they cannot cure the condition. Behavioral techniques can dramatically improve chronic insomnia in many cases, and the benefits of psychological and behavioral therapy are long-lasting. Behavioral methods work for all age groups, including children and older adults.

Sleep hygiene practices, tips and techniques for ensuring a good night's sleep, should accompany any behavioral method. (For more on sleep hygiene, see the Lifestyle Changes section of this report.)

Behavioral methods include:

  • Stimulus control
  • Cognitive-behavioral therapy
  • Relaxation training and biofeedback
  • Sleep restriction

All behavioral approaches have the same basic goals:

  • To reduce the time it takes to go to sleep to less than 30 minutes
  • To reduce the frequency and length of wake periods during the night

Studies report that the majority of people who are treated with non-drug methods experience improved sleep. Furthermore, most of those who have been taking sleep medications are able to stop or reduce their use.

Stimulus Control

Stimulus control is considered the standard treatment for primary chronic insomnia and may also be helpful for some people with secondary insomnia. The primary goal of stimulus control is to regain the idea that the bed is for sleeping. It involves the following:

  • Use the bed only for sleep and sex.
  • Go to bed only when ready to sleep.
  • If unable to sleep within 15 to 20 minutes, get up and go into another room. (People who find it physically difficult to get out of bed should sit up and do something relatively arousing, like reading a book.)
  • Avoid naps.

Cognitive-Behavioral Therapy

Cognitive-behavioral therapy (CBT) is a form of therapy that emphasizes observing and changing negative thoughts about sleep such as, "I'll never fall asleep." It uses actions intended to change behavior. The goal is to change or correct misconceptions about the ability to fall and stay asleep. Emphasis is on reinforcing the need for 7 to 8 hours of sleep each night and addressing the anxiety that people with insomnia often develop around sleep. Many studies have shown CBT to work as well or better than drugs. According to several studies, adding medication to CBT does not provide additional benefit.

Relaxation Training and Biofeedback

Relaxation training includes breathing and guided imagery techniques. Progressive muscle relaxation is another technique for inducing sleep that works well for many people. It takes about 10 minutes to perform and involves the following:

  • Relax the foot, and let it become loose and limp. Stay relaxed for 15 seconds, and then repeat with the other foot.
  • Move up to the next muscle group and repeat the sequence, doing one side of the body at a time. Move progressively from each foot and leg, up through the abdomen and chest, to each hand and arm, then to the neck, shoulders, and face.

Biofeedback may be combined with relaxation techniques. Biofeedback involves being monitored with an electroencephalogram (EEG), a device that measures brain waves. People are given feedback to recognize certain states of tension or sleep stages so that they can either avoid or repeat them voluntarily.

Paradoxical Intention and Sleep Restriction Therapies


Sleep restriction therapy is similar to paradoxical intention. It involves limiting the time spent in bed to the number of hours that are actually spent asleep. Eventually, the sleep loss helps some people fall asleep faster and spend more time asleep. As sleep improves, the hours spent in bed are increased.

Treatment of Underlying Mental Health Problems

Disruption in sleep is commonly present in those with mental health problems, such as certain types of depression, bipolar disorder, anxiety disorders, attention deficit disorders, alcohol and substance abuse, psychosis, and others.

When a sleep problem accompanies any of these disorders, it is important that the underlying mental health problem is treated also.

Drug Therapy

Unlike behavioral treatment, which can cure insomnia, sleeping pills produce only temporary improvement. Medications for insomnia can also have some serious side effects and risks, especially for older people. In general, the following considerations are important when using medications for the treatment of insomnia:

  • Non-benzodiazepine and other newer sedative hypnotics are the preferred medications for insomnia and have less risk for dependency than other drugs, such as benzodiazepines. However, these drugs may cause hazardous or strange sleep-related behaviors. They can also impair driving and mental alertness the next day. If you need to take one of these prescription drugs, start with as low a dose as possible.
  • For adults over age 60 years, the risks for sedative hypnotics may far outweigh their benefits. Sleep medications increase the risks for falls, depression, and memory loss in older people. Older people should generally start sleep medications at lower doses than younger people.
  • As a general rule, do not take either prescription or nonprescription sleeping pills on consecutive days or for more than 2 to 4 days a week.
  • Medication should be withdrawn gradually, and the person should be aware of the possibility of rebound insomnia after stopping medication. Rebound insomnia is the return of insomnia after medication is discontinued. It usually lasts for several days and can be more severe than the original insomnia.
  • If insomnia is still a problem after stopping the medication and continuing with good sleep hygiene, this pattern can be repeated again, but for only up to 4 weeks.

Lifestyle Changes

Sleep Hygiene Tips


During the day:

  • Avoid naps, especially in the evening.
  • Exercise before dinner. Stimulation from exercise drops to a low point a few hours after exercise, making sleep easier.
  • Exercising close to bedtime may increase alertness.
  • Eat light meals, and schedule dinner 4 to 5 hours before bedtime. A light snack before bedtime can help sleep, but a large meal may have the opposite effect.
  • Spend at least half an hour in daylight every day. The best time is early in the day.

Before and at bedtime:

  • Use the bed for sleep and sexual relations only, and not for reading, watching television, or working. Excessive time in bed disrupts sleep.
  • Take a hot bath about 1.5 to 2 hours before bedtime to help fall asleep.
  • Keep the bedroom relatively cool and well ventilated.
  • Avoid alcohol in the hours before bedtime. While alcohol may help you fall asleep quickly, it can cause you to wake up in the middle of the night.

If you are having problems falling asleep:

  • If still awake after 15 to 20 minutes, go into another room, read or do a quiet activity using dim lighting until feeling very sleepy. Do not watch television or use bright lights.


Many Americans use some form of herbal, over the counter, or prescription sleep aid pill. Over-the-counter (nonprescription) medications make use of the drowsiness caused by some common medications. Prescription drugs used specifically for improving sleeping are called sedative hypnotics.

Herbs and Supplements

More than 1.5 million Americans use complementary and alternative therapies to treat insomnia. Valerian and melatonin are among the most popular herbal and supplement remedies for insomnia. Chamomile tea and lemon balm are also popular. These substances are generally harmless for most people. However, other herbs and supplements have more serious side effects and interactions.




Melatonin is the most studied dietary supplement for insomnia. It appears to reduce the time to fall asleep (sleep onset) and may be effective in treating delayed sleep phase syndrome. However current evidence does not support the use of melatonin for primary or secondary insomnia. There are no consistent standards on melatonin doses and its safety has only been assessed for short-term use. General recommendations are to take 0.3 mg to 1 mg about 90 minutes before going to sleep. Taking higher doses may disrupt sleep and may cause daytime sleepiness, headaches, dizziness, nausea, and stomach cramps.

Valerian root



Kava has been used to relieve anxiety and improve sleep. It is dangerous and associated with reports of liver failure and death, with highest risk in those with liver disease. Kava can interact dangerously with certain medications, including alprazolam, an anti-anxiety drug. Kava also increases the strength of certain other drugs, including other sleep medications, alcohol, and antidepressants. Do not use this herb.

Tryptophan and 5-hydroxy-L-tryptophan (5-HTP)

Tryptophan is an amino acid used in the formation of the neurotransmitter serotonin, which is associated with healthy sleep. L-tryptophan used to be marketed for insomnia and other disorders but was withdrawn after contaminated batches caused a rare but serious, and even fatal, disorder called eosinophilia myalgia syndrome. A byproduct of tryptophan, 5-HTP, is still available as a supplement. There is little evidence that 5-HTP relieves insomnia.

Sleep Medications

Certain Nonprescription Antihistamines



Unfortunately, most of these drugs leave people feeling drowsy the next day and may not be very effective in providing restful sleep. Side effects include:

  • Daytime sleepiness
  • Cognitive impairment
  • Dizziness
  • Drunken movements
  • Blurred vision
  • Dry mouth and throat

In general, people with angina, heart arrhythmias, glaucoma, or problems urinating should avoid these drugs. They should not be used at the same time as medications that prevent nausea or motion sickness. People with chronic lung disease should also avoid some nonprescription sleeping aids, such as those containing doxylamine.

Nonprescription Pain Relievers


Sedative hypnotics

Sedative hypnotics include benzodiazepines and non-benzodiazepines, which enhance the effects of the brain chemical (neurotransmitter) GABA. When GABA binds to GABA receptors, brain activity slows down, inducing calm and relaxation. There are also new types of sedative hypnotics that work in a different way by targeting receptors for melatonin or orexin.


  • Rebound insomnia can occur after stopping the drug. It typically causes 1 to 2 nights of sleep disturbance, daytime sleepiness, and anxiety. In some cases, people may experience a temporary worsening of long-term insomnia.

Non-Benzodiazepine Hypnotics

Non-benzodiazepines (also called "Z" drugs) are the preferred sedative hypnotic drugs for the treatment of insomnia. In general, non-benzodiazepine hypnotics are recommended for short-term use (7 to 10 days), and treatment should not exceed 4 weeks.

Non-benzodiazepine hypnotics currently approved in the United States are:

  • Zolpidem (Ambien, Ambien CR, generic) is the most commonly prescribed drugs for insomnia. Because it is long-lasting, people should not take it unless they plan on getting at least 7 to 8 hours of sleep. A lower-dose, sublingual (under-the-tongue) formulation of zolpidem (Intermezzo) is approved for people who wake up abruptly in the middle of the night and have trouble falling back asleep. People take it as needed when they awaken in the night but must be able to get at least 4 hours of sleep after taking.


For all sleeping pills, the lowest dose that achieves symptom relief should be the chosen dose.

Recommended dosage for zolpidem products:

  • All zolpidem products now have lower recommended bedtime dosages.
  • Women have lower recommended dosages than men (women metabolize zolpidem more slowly than men and are more susceptible to next-day mental impairment).

Lower dose recommendations are also in place for eszopiclone, which can cause impairment in driving and cognitive skills for up to 11 hours after an evening dose. The FDA is currently reviewing all sleep medications to evaluate how they affect next-day mental alertness.

Side Effects

Non-benzodiazepines tend to have fewer side effects than benzodiazepines because they target the GABA receptor in a more specific way. However, these drugs can still cause residual morning sedation even if you are feeling fully awake. When people first start taking any of these drugs, they should use caution during morning activities until they are sure how the drug affects them.

General side effects may include:

  • Drowsiness
  • Dizziness
  • Fatigue
  • Headache
  • Diarrhea or constipation

All non-benzodiazepine drugs carry labels warning that these drugs can cause strange sleep-related behavior, including driving, making phone calls, and preparing and eating food while asleep. Most cases of sleepwalking and sleepdriving likely occur when people use the drug along with alcohol or other drugs or take more than the recommended dose. The FDA recently added a boxed warning on rare but serious injuries related to sleepwalking and sleepdriving related to eszopiclone (Lunesta), zaleplon (Sonata), and zolpidem (Ambien, Ambien CR, Edluar, Intermezzo, Zolpimist).

Anyone who receives a prescription for these medicines will get a patient medication guide explaining the risks for the drugs and the precautions to take. Talk to your doctor if you have any questions concerning these drugs or their potential side effects.

Carefully read the information labels for all drugs and follow the directions. Some sleeping pills take 30 to 60 minutes to take effect, while others (such as zolpidem) act quickly. For zolpidem, people should:

  • Take zolpidem immediately before going to sleep
  • Take zolpidem only when able to get a full night's sleep (7 to 8 hours)
  • Not drink alcohol the same evening
  • Not take more than the prescribed dose


As with any hypnotic, alcohol increases the sedative effects of these drugs. These hypnotics also interact with other drugs. Inform your doctor of all your medications.

Rebound Insomnia, Dependence, and Tolerance

The risk for rebound insomnia, dependence, and tolerance is lower with non-benzodiazepine hypnotics than with benzodiazepine drugs. These drugs are still subject to abuse. In any case, no hypnotic should be taken for more than 7 to 10 days in a row or at higher than the recommended dose without a doctor's approval.

Benzodiazepine Hypnotics


Commonly prescribed benzodiazepines are:


Side Effects


Side effects may differ depending on whether the benzodiazepine is long- or short-acting. They include:

  • Respiratory problems (especially reducing how often or how deeply one breathes), which may occur with overuse or in people with pre-existing respiratory illness.
  • Worsening of depression, a common condition in many people with insomnia.
  • Residual daytime drowsiness, which is common with benzodiazepines. Long-acting benzodiazepines pose a higher risk than shorter-acting benzodiazepines.
  • Urinary incontinence may occur, particularly in older people and when taking long-acting formulations.
  • In pregnant and nursing women, birth defects are a risk because these drugs cross the placenta and enter breast milk. Pregnant women or nursing mothers should not use these medications. Benzodiazepine use in the first trimester of pregnancy may be associated with the development of cleft lip in newborns.
  • Although rare, fatal overdoses can occur.


Benzodiazepines are potentially dangerous when combined with alcohol. Some medications, like ulcer and acid reflux medications in the histamine receptor-2 blocker class (such as cimetidine, Tagamet), can slow the metabolism of the benzodiazepine.

Withdrawal Symptoms


  • Gastrointestinal distress
  • Sweating
  • Disturbed heart rhythm
  • Rebound insomnia (the risk is higher with short-acting benzodiazepines than with long-acting ones)
  • In severe cases, hallucinations or seizures

Other Types of Sedative Hypnotics

Ramelteon (Rozerem, generic)

Ramelteon is a type of sedative hypnotic called a melatonin receptor agonist. Unlike non-benzodiazepines or benzodiazepines, which target GABA receptors, ramelteon works by targeting melatonin receptors. Ramelteon is not habit forming and is the first sleep drug that is not designated as a controlled substance. A related melatonin receptor agonist, tasimelteon (Hetlioz), is approved for treating circadian rhythm disorders in people who are blind.

Dual orexin receptor antagonists (DORAs)

Suvorexant (Belsomra) was the first FDA-approved dual orexin receptor antagonist (DORA) sleep drug. Suvorexant targets and blocks the action of orexin. Orexin (also called hypocretin) is a chemical produced in the hypothalamus part of the brain, which is involved in regulating the sleep-wake cycle and keeping people awake. In 2019, the FDA approved another orexin receptor antagonist called lemborexant (Dayvigo). Like suvorexant, lemborexant acts on both orexin receptors. DORAs are controlled substances, which means they can potentially be abused or cause dependence. Like other sleep medications, DORAs may cause sleep-related behaviors such as sleepdriving.


Antidepressants are often helpful in treating insomnia even when anxiety or major depression are not present. Certain types of antidepressants with sedating properties are prescribed for the treatment of primary insomnia, generally in lower doses than used to treat depression.


Precautions should be taken in the use of trazodone and other sedating antidepressants in older people, due to the risk for side effects (daytime sleepiness, dizziness, priapism, and increased risk of falls) and drug interactions.


Similarly to benzodiazepines, barbiturates are central nervous system depressants that stimulate GABA receptors and thus inhibit nerve cells. Barbiturates were commonly used for insomnia treatment in the past, as well as for epilepsy, anxiety, and anesthesia, but have now been almost entirely replaced by newer, safer drugs in most regions of the world. A few barbiturates that are FDA-approved for the short treatment of insomnia are still marketed in the United States, including secobarbital (Seconal) and butabarbital (Butisol). These drugs are controlled substances and are rarely used today.



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        Review Date: 3/27/2020  

        Reviewed By: Christos Ballas, MD, Private Practice specializing in Forensic Psychiatry, Philadelphia, PA. Review provided by VeriMed Healthcare Network. Also reviewed by David Zieve, MD, MHA, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.


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