One-liner#

Evaluate insomnia to identify underlying causes and comorbidities, prioritize CBT-I as first-line treatment, and use medications judiciously while avoiding long-term hypnotic dependence.

Quick nav#

• Red flags / send to ED
• Key history
• Focused exam
• Differential (quick pattern recognition)
• Workup
• Initial management
• Management by diagnosis
• Follow-up
• Patient instructions
• Smartphrase snippets

Red flags / send to ED#

• Insomnia rarely requires ED evaluation

Urgent (not ED, but expedited):

• Severe sleep deprivation with safety concerns (driving, operating machinery)
• Insomnia with active suicidal ideation
• Suspected severe sleep apnea with daytime somnolence and safety risk

Key history#

Characterize the insomnia:

• Sleep-onset insomnia: trouble falling asleep (>30 min)
• Sleep-maintenance insomnia: frequent awakenings, trouble returning to sleep
• Early morning awakening: waking too early, can’t return to sleep
• Duration: acute (<3 months) vs chronic (≥3 months, ≥3 nights/week)

Sleep diary (ask patient to keep for 1-2 weeks):

• Bedtime and wake time
• Time to fall asleep
• Number and duration of awakenings
• Total sleep time
• Daytime naps
• Caffeine, alcohol, medication use

Sleep hygiene assessment:

• Consistent sleep/wake times?
• Screen use before bed (phone, TV, computer)
• Caffeine intake and timing
• Alcohol use (disrupts sleep architecture)
• Exercise timing (late exercise can disrupt sleep)
• Bedroom environment (dark, cool, quiet)
• Bed used only for sleep and sex?

Screen for underlying causes:

Psychiatric:

• Depression (early morning awakening classic)
• Anxiety (sleep-onset insomnia, racing thoughts)
• PTSD (nightmares, hypervigilance)
• Mania/hypomania (decreased need for sleep)

Medical:

• Pain (arthritis, neuropathy, cancer)
• Dyspnea (HF, COPD, asthma)
• GERD (nocturnal symptoms)
• Nocturia (BPH, diabetes, diuretics)
• Restless legs syndrome
• Hyperthyroidism
• Menopause (hot flashes)

Sleep disorders:

• Sleep apnea: snoring, witnessed apneas, gasping, morning headaches, daytime sleepiness
• Restless legs syndrome: urge to move legs, worse at rest, worse at night, relieved by movement
• Circadian rhythm disorders: delayed sleep phase (night owl), advanced sleep phase (elderly)

Medications that disrupt sleep:

• Stimulants (methylphenidate, amphetamines)
• Decongestants (pseudoephedrine)
• Beta-blockers (nightmares, sleep disruption)
• Corticosteroids
• SSRIs (can cause insomnia or sedation)
• Diuretics (nocturia)
• Thyroid hormone (if overreplaced)
• Caffeine (including in medications)

Substance use:

• Caffeine: amount, timing (half-life 5-6 hours)
• Alcohol: may help initiate sleep but disrupts sleep architecture
• Cannabis: may help short-term but tolerance develops
• Nicotine: stimulant effect

Focused exam#

General:

• BMI (obesity → sleep apnea risk)
• Signs of sleep deprivation (fatigue, irritability)

HEENT:

• Mallampati score (airway crowding → sleep apnea)
• Neck circumference >17" (men) or >16" (women) → sleep apnea risk
• Nasal obstruction

Cardiovascular:

• Hypertension (associated with sleep apnea)
• Signs of heart failure

Neurologic:

• Restless legs (observe for movements)
• Signs of neuropathy

Psychiatric:

• Mental status exam for depression, anxiety, mania

Differential (quick pattern recognition)#

Common/likely (outpatient)#

Can’t-miss / urgent#

Workup#

Most insomnia is diagnosed clinically. Labs only if medical cause suspected.

Consider based on presentation:

STOP-BANG score for sleep apnea:

• Snoring (loud)
• Tired (daytime sleepiness)
• Observed apneas
• Pressure (hypertension)
• BMI >35
• Age >50
• Neck circumference >40 cm (16")
• Gender male
• Score ≥3: intermediate-high risk → sleep study

When NOT to order sleep study:

• Clear primary insomnia without sleep apnea symptoms
• Insomnia clearly due to depression/anxiety
• Poor sleep hygiene as obvious cause

Initial management#

First-line for chronic insomnia: CBT-I (Cognitive Behavioral Therapy for Insomnia)

• More effective than medications long-term
• No side effects or dependence
• Effects persist after treatment ends
• Available in-person, online (Somryst FDA-cleared app), or self-guided

CBT-I components:

• Sleep restriction: limit time in bed to actual sleep time
• Stimulus control: bed only for sleep/sex; get up if awake >20 min
• Cognitive therapy: address catastrophic thoughts about sleep
• Sleep hygiene education
• Relaxation techniques

When to consider medications:

• CBT-I not available or patient declines
• Acute insomnia (<3 months) with clear precipitant
• Bridge while waiting for CBT-I to take effect
• Comorbid condition requiring pharmacotherapy

Medication principles:

• Use lowest effective dose
• Limit duration (2-4 weeks for most hypnotics)
• Plan for discontinuation from the start
• Avoid in elderly if possible (falls, cognitive impairment)

Management by diagnosis#

Chronic insomnia disorder (primary insomnia)#

Education:

• Insomnia is treatable
• CBT-I is more effective than pills long-term
• Sleep medications are not a long-term solution
• It takes time to reset sleep patterns

Treatment:

First-line: CBT-I

• Refer to sleep psychologist or behavioral sleep medicine
• Online options: Somryst (FDA-cleared), Sleepio, CBT-I Coach app
• Self-guided workbooks available

If medications needed:

Avoid in most patients:

Elderly considerations:

• CBT-I strongly preferred (no fall risk, no cognitive effects)
• If medication needed: low-dose trazodone or doxepin
• AVOID: benzodiazepines, zolpidem, diphenhydramine (Beers criteria)
• Start at lowest dose; “start low, go slow”

Pregnancy/breastfeeding:

• CBT-I is first-line and safe
• Avoid all hypnotics if possible
• If medication needed: diphenhydramine occasionally used (limited data)
• Melatonin: insufficient safety data; avoid
• Refer to MFM or psychiatry for complex cases

Tapering chronic hypnotic users:

• Gradual taper over weeks to months
• Reduce dose by 25% every 1-2 weeks
• Expect temporary worsening (rebound insomnia)
• Concurrent CBT-I dramatically improves success
• Switch to longer-acting agent if on short-acting (e.g., zolpidem → low-dose trazodone)
• For benzodiazepines: may need even slower taper (10% every 1-2 weeks)

Follow-up: 2-4 weeks to assess response; then monthly until stable.

Insomnia due to depression#

Education:

• Depression commonly causes sleep problems
• Treating depression often improves sleep
• May need both antidepressant and short-term sleep aid

Treatment:

• Treat underlying depression (see depression page)
• Sedating antidepressants can help sleep:
  • Mirtazapine 7.5-15 mg at bedtime (also helps appetite)
  • Trazodone 25-100 mg at bedtime (can add to SSRI)
• Avoid activating antidepressants at bedtime (fluoxetine, bupropion)

Follow-up: Per depression management; reassess sleep as depression improves.

Insomnia due to anxiety#

Education:

• Anxiety and insomnia feed each other
• Treating anxiety often improves sleep
• CBT-I addresses the anxiety-insomnia cycle

Treatment:

• Treat underlying anxiety (see anxiety page)
• CBT-I addresses racing thoughts and hyperarousal
• If medication needed: hydroxyzine 25-50 mg at bedtime (also treats anxiety)
• Avoid benzodiazepines for sleep (dependence, rebound)

Follow-up: Per anxiety management.

Obstructive sleep apnea#

Education:

• Sleep apnea causes fragmented sleep and daytime fatigue
• Untreated OSA increases cardiovascular risk
• CPAP is the gold standard treatment
• Weight loss can significantly improve or cure OSA

PCP role:

• Screen with STOP-BANG
• Refer for sleep study if score ≥3 or high clinical suspicion
• Refer to sleep medicine for CPAP initiation and management
• Support weight loss
• Manage comorbidities (HTN, diabetes)

Follow-up: Sleep medicine manages CPAP; PCP supports adherence and comorbidities.

Restless legs syndrome#

Education:

• RLS is a neurologic condition, not “just restlessness”
• Iron deficiency worsens RLS
• Medications can help significantly

Treatment:

Augmentation: Worsening of RLS symptoms with dopamine agonists over time; switch to gabapentinoid if occurs.

Follow-up: 4-6 weeks after starting treatment; then as needed.

Circadian rhythm disorders#

Delayed sleep phase (night owl):

• Common in adolescents/young adults
• Can’t fall asleep until 2-3am; sleeps fine once asleep
• Treatment: morning bright light therapy; low-dose melatonin 0.5-3 mg 5-7 hours before desired bedtime

Advanced sleep phase (early bird):

• Common in elderly
• Falls asleep at 7-8pm; wakes at 3-4am
• Treatment: evening bright light therapy; avoid morning light

Follow-up: 4-6 weeks to assess response.

Follow-up#

Initial:

• 2-4 weeks after starting treatment
• Review sleep diary
• Assess response to CBT-I or medication

Ongoing:

• Monthly until stable
• Taper medications when possible
• Reassess for underlying conditions if not improving

Return precautions:

• Daytime sleepiness affecting safety (driving)
• Symptoms of sleep apnea (snoring, witnessed apneas)
• Worsening depression or anxiety
• Medication side effects (next-day sedation, complex sleep behaviors)

When to refer:

• Suspected sleep apnea → sleep medicine
• Refractory insomnia despite CBT-I and medication trials → sleep medicine
• Complex sleep disorders (narcolepsy, parasomnias) → sleep medicine

Patient instructions#

• Good sleep habits are the foundation of better sleep. Go to bed and wake up at the same time every day, even on weekends.
• Use your bed only for sleep and sex. If you can’t sleep after 20 minutes, get up and do something relaxing until you feel sleepy.
• Avoid screens (phone, TV, computer) for at least 30 minutes before bed. The light tells your brain to stay awake.
• Limit caffeine, especially after noon. Avoid alcohol before bed—it may help you fall asleep but disrupts sleep later.
• If you’re prescribed a sleep medication, use it only as directed and for the shortest time needed. These are not meant for long-term use.
• Call us if you have loud snoring, stop breathing at night, or feel very sleepy during the day—you may need a sleep study.

Smartphrase snippets#

.INSOMNIAEVAL Chronic insomnia, [sleep-onset / sleep-maintenance / mixed]. Duration [X months/years]. Sleep diary reviewed. No symptoms concerning for sleep apnea (STOP-BANG [score]). Screen for depression/anxiety: [PHQ-9/GAD-7 scores]. Discussed CBT-I as first-line treatment. [Referral placed / online CBT-I resources provided]. Sleep hygiene counseling provided. Follow-up in 4 weeks.

.INSOMNIAMED Chronic insomnia with inadequate response to sleep hygiene measures. Starting [trazodone 25 mg / melatonin 3 mg] at bedtime. Discussed that sleep medications are for short-term use and CBT-I is more effective long-term. Avoid driving or operating machinery if sedated. Follow-up in 2-4 weeks to assess response and plan taper.

.INSOMNIARLS Restless legs syndrome based on clinical criteria: urge to move legs, worse at rest, worse at evening/night, relieved by movement. Ferritin [level] [ordered / low → starting iron supplementation]. Starting [gabapentin 300 mg at bedtime]. Discussed that symptoms may take several weeks to improve. Follow-up in 4-6 weeks.

Related pages#

• Chronic Insomnia (problem) — comprehensive ongoing management of chronic insomnia
• Obstructive Sleep Apnea (problem) — detailed OSA management including CPAP
• Depression — depression commonly causes insomnia
• Anxiety — anxiety commonly causes sleep-onset insomnia
• Fatigue — insomnia as cause of fatigue