Multiple insomnia medications exist with different mechanisms and side effect profiles. Insomnia medications should generally be considered after CBT-I or for short-term use. This guide compares options.
Z-drugs (Non-benzodiazepine hypnotics)
Zolpidem (Ambien): Most prescribed. Onset within 30 minutes, lasts 6-8 hours.
Eszopiclone (Lunesta): Longer half-life. Bitter taste side effect common.
Zaleplon (Sonata): Very short half-life. Useful for middle-of-night awakening.
Concerns: dependence, complex sleep behaviors, daytime impairment, falls in elderly.
DORAs (Dual orexin receptor antagonists)
Suvorexant (Belsomra)
Lemborexant (Dayvigo)
Daridorexant (Quviviq)
Newer mechanism. Less dependence concerns than Z-drugs. Effective for sleep onset and maintenance. More expensive.
Melatonin agonists
Ramelteon (Rozerem): Selective melatonin receptor agonist. Particularly for sleep onset. No dependence potential.
Off-label options
Trazodone: Most prescribed sleep medication despite off-label use. Low doses (25-100 mg). Limited efficacy data but widely used.
Mirtazapine: Sedating antidepressant, sometimes used for sleep.
Quetiapine (Seroquel): Off-label for sleep — controversial due to metabolic side effects without strong sleep evidence.
Doxepin (low-dose Silenor): Approved for sleep maintenance.
Older options
Benzodiazepines (temazepam, triazolam, etc.): Older sleep medications. Dependence concerns. Some specific uses remain.
OTC options
- Doxylamine (Unisom): Most evidence among OTCs
- Diphenhydramine (Benadryl): Anticholinergic concerns
- Melatonin: Modest effect, particularly for circadian issues
Choosing medication
Considerations:
- Acute vs chronic insomnia
- Sleep onset vs maintenance problem
- Comorbidities
- Other medications
- Age (elderly more vulnerable to side effects)
- Substance use history (avoid Z-drugs)
- Cost
Frequently Asked Questions
What’s the best sleep medication?
Depends on patient. DORAs generally favored for chronic use due to less dependence.
Are Z-drugs addictive?
Can produce dependence and tolerance. Less than benzos but real concern.
Is trazodone better than Ambien?
Different profiles. Trazodone less dependence; Ambien more sleep-specific evidence.
How long can I take sleep medication?
Short-term ideal. Long-term use should prompt CBT-I.
Are sleep medications safe in elderly?
Increased fall and cognitive risk. Consider alternatives carefully.
The bottom line on insomnia medications
Multiple options with different profiles. DORAs favored for newer use. CBT-I should be tried for chronic insomnia. Discuss with prescriber.