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Insomnia

What's new

The United States Department of Veterans Affairs (VA) and Department of Defense (DoD) have updated their guidelines for the management of chronic insomnia disorder. First-line treatment remains cognitive behavioral therapy for insomnia (CBT-I), recommended over pharmacotherapy, with brief behavioral therapy for insomnia (BBT-I) as an alternative. Sleep hygiene education should not be used as a standalone treatment. For patients offered pharmacotherapy, suggested agents include orexin receptor antagonists (aridorexant, lemborexant, suvorexant), nonbenzodiazepine hypnotics (eszopiclone, zaleplon, zolpidem), and doxepin. Antipsychotics, benzodiazepines, diphenhydramine, trazodone, melatonin, and cannabis are not recommended. .

Background

Overview

Definition
Insomnia is a sleep disorder characterized by persistent symptoms of trouble falling asleep, staying asleep, or waking up too early in the morning accompanied by at least one symptom of impaired daytime function (not getting enough sleep or daytime sleepiness).
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Pathophysiology
Insomnia is caused by a hyperarousal state primarily due to physiologic or neurophysiologic factors.
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Risk factors
Risk factors for insomnia include advancing age, female sex, depression, anxiety disorders, night shift or rotating shift work, chronic conditions causing dyspnea, GERD, chronic pain conditions, neurodegenerative diseases, restless leg syndrome, periodic limb movement disorders, snoring, and sleep apnea.
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Disease course
Insomnia is characterized by difficulty sleeping, frequent nocturnal awakening, prolonged periods of wakefulness during sleep period, and poor quality sleep. Insomnia impacts physical functioning, role limitation due to physical and emotional health problems, body pain, general health perceptions, vitality, social functioning, and mental health.
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Prognosis and risk of recurrence
Persistent insomnia has been associated with an increased risk of all-cause mortality (HR 1.58, 95% CI 1.02-2.45), while intermittent insomnia has not been associated with an increased risk.
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Guidelines

Key sources

The following summarized guidelines for the evaluation and management of insomnia are prepared by our editorial team based on guidelines from the American Academy of Sleep Medicine (AASM 2025,2018,2017), the United States Department of Defense (DoD/VA 2025,2016), the American Academy of Family Physicians (AAFP 2024,2017), the Canadian Expert Group on Cannabinoids Use in Chronic Pain (CCP-CEG 2023), the European Sleep ...
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Diagnostic investigations

History and physical examination: as per DoD/VA 2025 guidelines, consider screening patients with sleep complaints for insomnia using validated screening instruments, such as the Insomnia Severity Index or Athens Insomnia Scale, to identify patients who require further evaluation.
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  • Actigraphy

  • Polysomnography

  • Additional testing

Medical management

General principles
As per AAFP 2024 guidelines:
Offer medications for the treatment of insomnia, but discourage their long-term use (> 3 months).
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Avoid benzodiazepines and nonbenzodiazepine hypnotics if possible because of significant long- and short-term safety concerns.
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  • Benzodiazepines

  • Nonbenzodiazepines (prescribing)

  • Nonbenzodiazepines (deprescribing)

  • Melatonin receptor agonists (melatonin)

  • Melatonin receptor agonists (ramelteon)

  • Orexin receptor antagonists

  • Antidepressants

  • Antipsychotics (prescribing)

  • Antipsychotics (deprescribing)

  • Anticonvulsants

  • Antihistamines

Nonpharmacologic interventions

Sleep hygiene education: as per DoD/VA 2025 guidelines, avoid using sleep hygiene education as a standalone treatment for chronic insomnia disorder.
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  • CBT-I

  • Mindfulness-based interventions

  • Light therapy

  • Alternative and complementary medicine

Specific circumstances

Pediatric patients: as per BAP 2019 guidelines, offer behavioral strategies as first-line therapy in pediatric patients with disturbed sleep.
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  • Pregnant patients

  • Menopausal patients

  • Elderly patients

  • Critically ill patients

  • Patients with restless legs syndrome

  • Patients with periodic limb movements of sleep

  • Patients with intellectual disability

  • Patients with dementia

  • Patients with cancer (evaluation)

  • Patients with cancer (psychotherapy)

  • Patients with cancer (pharmacotherapy)

  • Patients with cancer (other therapies)

  • Patients with Parkinson's disease (evaluation)

  • Patients with Parkinson's disease (management)

  • Patients with Huntington's disease

  • Patients with ALS

  • Patients with multiple sclerosis

  • Patients with mild traumatic brain injury (evaluation)

  • Patients with mild traumatic brain injury (management)

  • Patients with autism spectrum disorder