Practice Essentials
Insomnia is defined as repeated difficulty with sleep initiation, maintenance, consolidation, or quality that occurs despite adequate time and opportunity for sleep and that results in some form of daytime impairment. As many as 95% of Americans have reported an episode of insomnia at some point during their lives.
Signs and symptoms
The American Academy of Sleep Medicine (AASM) guideline consensus is that, at a minimum, patients with insomnia should complete the following evaluations:
A general medical and psychiatric questionnaire to detect comorbid disorders
A sleepiness assessment, such as the Epworth Sleepiness Scale
A 2-week sleep log to define sleep-wake patterns and their variability
A careful sleep history should be obtained, addressing the following:
Timing of insomnia
Patient’s sleep habits (commonly referred to as sleep hygiene)
Presence or absence of symptoms of sleep disorders associated with insomnia
A thorough medical history should be obtained, including a review of systems.
A thorough psychological history should be obtained to screen for psychiatric disorders, focusing particularly on anxiety and depression.
A family history should be obtained, with particular attention to the following:
Risk of fatal familial insomnia (FFI): Though rare, this condition should be considered if first-degree relatives are affected
Risk of heritable conditions that may contribute to more common causes of insomnia (eg, psychiatric disorders)
A social history should be obtained, addressing the following:
Transient or short-term insomnia: Recent situational stresses
Chronic insomnia: Past stresses or medical illnesses
Use of tobacco, caffeinated products, alcohol, and illegal drugs
The medication history should be reviewed, focusing on agents that commonly cause insomnia, such as the following:
Beta blockers
Clonidine
Theophylline (acutely)
Certain antidepressants (eg, protriptyline, fluoxetine)
Decongestants
Stimulants
Over-the-counter and herbal remedies
Physical examination may offer clues to underlying medical disorders predisposing to insomnia.
Specific recommendations include the following:
History suggestive of sleep apnea: Careful head and neck examination
Symptoms of restless legs syndrome or periodic limb movement disorder or any other neurologic disorder: Careful neurologic examination
Daytime symptoms consistent with a medical cause of insomnia: Careful examination of the affected organ system (eg, lungs in chronic obstructive pulmonary disease)
See Clinical Presentation for more detail.
Diagnosis
Insomnia is a clinical diagnosis. Diagnostic studies are indicated principally for the clarification of comorbid disorders. Measures that may be considered include the following:
Studies for hypoxemia
Polysomnography and daytime multiple sleep latency testing (MSLT)
Actigraphy
Sleep diary
Genetic testing (eg, for FFI)
Brain imaging (eg, to assist in the diagnosis of FFI
)
See Workup for more detail.
Management
The AASM guidelines list two primary treatment goals, as follows:
To improve sleep quality
To improve related daytime impairments
The AASM guidelines recommend including at least one behavioral intervention in initial treatment. Cognitive-behavioral therapy (CBT) is considered the most appropriate treatment for patients with primary insomnia, though it is also effective for comorbid insomnia as adjunctive therapy.
The components of CBT include the following:
Sleep hygiene education
Cognitive therapy
Relaxation therapy
Stimulus-control therapy
Sleep-restriction therapy
Sedative-hypnotics are the most commonly prescribed drugs for insomnia. Though not usually curative, they can provide symptomatic relief when used alone or adjunctively. Such agents include the following:
Short- and intermediate-acting benzodiazepines (eg, triazolam, temazepam, estazolam)
Eszopiclone
Zolpidem
Zaleplon
Ramelteon
The following general precautions should be taken when sedative-hypnotics are used:
Start with a low dose, and maintain at the lowest effective dose
Avoid continued nightly use; encourage patients to use them only when truly necessary
Avoid using for more than 2-4 weeks if possible
Counsel patients to allow for at least 8 hours of sleep
Be aware that impairment can be present despite a feeling of being fully awake
When the problem is falling asleep, prefer hypnotics with a rapid onset of action (eg, zolpidem, zaleplon)
When the problem is staying asleep, consider a hypnotic with a slower rate of elimination (eg, temazepam, estazolam, flurazepam)
If the patient is depressed, consider an antidepressant with sedative properties (eg, trazodone, mirtazapine, amitriptyline) in preference to a hypnotic
Never use hypnotics with alcohol
Avoid using in pregnant patients
Avoid using benzodiazepines in patients with known or possible sleep apnea
Use lower doses in elderly patients
Sedating antidepressants used in the treatment of insomnia include the following:
Amitriptyline
Nortriptyline
Doxepin
Mirtazapine
Trazodone
Other measures that may be helpful include the following:
Acupressure
Dietary modification
Exercise (at least 6 hours before bedtime)
See Treatment and Medication for more detail.