In general, a sedative-hypnotic drug for the management of insomnia should be prescribed only as a short-term aid during an illness or some unusual circumstance, that is, for acute insomnia. For patients who have difficulty falling asleep, a quick-acting, fairly rapidly metabolized hypnotic is useful. The most commonly used medications were the benzodiazepine receptor agonists, which act on the gamma-aminobutyric acid, GABA-A receptor complex. Benzodiazepines were popular but these have been largely replaced by nonbenzodiazepines, GABA-A α1-receptor agonists, with shorter half-lives and perhaps fewer side effects (e.g., zolpidem, zaleplon, and eszopiclone). Patients who do not respond to these medications may be given an intermediate-duration benzodiazepine such as temazepam. There is also a newer class of medications, which act as orexin receptor antagonists, typified by suvorexant. Hypnotic use is inadvisable during pregnancy and should be used cautiously in patients with alcoholism or advanced renal, hepatic, or pulmonary disease, and should be avoided in patients with sleep apnea syndrome.
Melatonin (3 to 12 mg) has reportedly been as effective as the sedative hypnotics and may cause fewer short-term side effects, but both of these statements are difficult to confirm. Melatonin has a short half-life, and it has only weak hypnotic effect. Therefore, for sleep rhythm disturbances, it is ideally taken 3 to 4 hours before sleep time. Tricyclic antidepressants appear to be sleep enhancing even in those who are not anxious or depressed. Tolerance develops to the drug, and there are morning side effects so the drug may find its best use in patients who are taking it for alternative reasons such as headache or depression. Some practitioners indicate that antidepressants may also worsen restless leg or periodic leg movement disorders. When pain is a factor in insomnia, the sedative may be combined with a suitable analgesic. Nonprescription drugs containing diphenhydramine (Benadryl), valerian, or doxylamine, which are minimally or not at all effective in inducing sleep, may impair the quality of sleep and lead to drowsiness the following morning.
The chronic insomniac who has no other symptoms should be discouraged from using sedative drugs. The solution of this problem is rarely to be found in medication. One should search out and correct, if possible, any underlying situational or psychologic difficulty, using medication only as a temporary measure. Patients should be encouraged to regularize their daily schedules, including their bedtimes, and to be physically active during the day but to avoid strenuous physical and mental activity before bedtime. It has been suggested that illumination from broad-spectrum light (television) in the late evening is detrimental. Dietary excesses must be corrected, and all nonessential medications interdicted. Coffee and alcohol should be avoided at night, if not throughout the day. A number of simple behavioral modifications may be useful, such as using the bedroom only for sleeping, arising at the same time each morning regardless of the duration of sleep, avoiding daytime naps, and limiting the time spent in bed strictly to the duration of sleep. A helpful approach is to lessen the patient’s concern about sleeplessness by pointing out that he will always get as much sleep as needed and that there is pleasure to be derived from staying awake and reading, or viewing a movie.
Restless Legs Syndrome, Periodic Leg Movements of Sleep, and Related Disorders