Insomnia

Audience: Patients and providers
Status: Clinical guide · patient + provider
Last updated: 2026-03-09

1. Clinical overview

Insomnia is difficulty initiating sleep, maintaining sleep, or achieving restorative sleep despite adequate opportunity, with daytime impairment and frequent overlap with mood, pain, and breathing disorders.

2. Common causes and risk factors

Hyperarousal disorder often linked to stress, circadian disruption, comorbid mood/pain conditions.
Contributors: inconsistent sleep schedules, substance use, untreated OSA/restless legs.

3. Typical symptoms

Difficulty initiating or maintaining sleep with daytime impairment.

4. Diagnosis and evaluation

Confirm diagnosis with guideline-based history, exam, and indicated testing.
Screen for severity, complications, and high-risk comorbid conditions.
Identify social or access barriers that could affect treatment success.

5. Treatment (non-pharmacologic)

CBT-I is first-line treatment.
Sleep schedule regularization, light exposure timing, and stimulus control.
Address comorbid anxiety, depression, pain, and breathing disorders.

6. Treatment (pharmacologic)

Medication should be adjunctive to CBT-I, with common options including doxepin for sleep maintenance, ramelteon for sleep onset, and dual orexin receptor antagonists such as suvorexant, lemborexant, or daridorexant.
Z-drugs such as zolpidem, zaleplon, or eszopiclone may help selected short-term cases but require close attention to next-day impairment and complex sleep behaviors.
Trazodone, hydroxyzine, and benzodiazepines are commonly used in practice but should be chosen cautiously and reassessed regularly for sedation, falls, and dependence.

7. Monitoring and follow-up

Sleep diary metrics, daytime function, falls/cognitive effects, medication dependence risk.

8. Practical counseling points

Give patients a clear “what to do today / when to call / when to seek urgent care” plan.
Use teach-back to confirm understanding of treatment goals and medication instructions.
Simplify regimens when possible to improve adherence and outcomes.

9. Red flags and escalation

Escalate care urgently for severe or rapidly worsening symptoms.
Reassess diagnosis if expected response does not occur within the anticipated timeline.

10. Guideline references

Note: Educational guide only; not a substitute for individualized medical care.