Insomnia — difficulty falling asleep, staying asleep, or waking too early — affects roughly 30% of adults at some point. While occasional sleeplessness is normal, chronic insomnia (3+ nights per week for 3+ months) significantly impacts quality of life, mental health, and physical well-being. Understanding the treatment landscape helps make informed decisions.

Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment by every major sleep medicine society. It addresses the thoughts and behaviors that perpetuate insomnia through sleep restriction, stimulus control, relaxation techniques, and cognitive restructuring. CBT-I is as effective as medications in the short term and more effective in the long term, without any risk of dependence.

Melatonin is a hormone that regulates the sleep-wake cycle, not a sedative. It is most effective for circadian rhythm disorders (jet lag, shift work, delayed sleep phase) and may modestly reduce sleep onset time. Doses of 0.5–3 mg taken 1–2 hours before bedtime are typical; higher doses are not more effective and may cause morning grogginess. In the EU, prolonged-release melatonin (Circadin) is approved for patients over 55.

Diphenhydramine and doxylamine (first-generation antihistamines) are the active ingredients in most OTC sleep aids. They cause drowsiness by blocking H1 receptors in the brain. Tolerance develops within days, anticholinergic side effects are common, and they are associated with cognitive impairment and increased dementia risk in the elderly. They should not be used for chronic insomnia.

Zolpidem (Z-drug) acts on GABA-A receptors and is effective for sleep onset insomnia. It can cause complex sleep behaviors (sleepwalking, sleep-driving) and has dependence potential. Trazodone (an antidepressant at low doses) is widely used off-label for insomnia; it's less habit-forming but can cause orthostatic hypotension and priapism (rare). Low-dose doxepin (3–6 mg) is the only antidepressant FDA-approved specifically for sleep maintenance insomnia. Suvorexant and lemborexant (orexin receptor antagonists) represent a newer class with a different mechanism.

Benzodiazepines (diazepam, temazepam) are effective but carry significant risks: tolerance, dependence, rebound insomnia, falls in elderly, cognitive impairment, and potentially life-threatening withdrawal. They should be reserved for short-term use only. Alcohol is a poor sleep aid — it may help falling asleep but fragments sleep architecture and suppresses REM sleep.

Maintain a consistent sleep schedule. Avoid screens for 1 hour before bed. Keep the bedroom cool, dark, and quiet. Limit caffeine after noon. Exercise regularly but not within 3 hours of bedtime. Don't lie in bed awake for more than 20 minutes — get up, do something quiet, and return when sleepy.

Consult a healthcare provider if insomnia persists despite good sleep hygiene, if you snore loudly or stop breathing during sleep (possible sleep apnea), or if you feel excessively sleepy during the day despite adequate sleep time. A sleep study may be recommended to rule out other sleep disorders.