Insomnia: Over the Counter and Prescription Products for Sleep

Overview

Insomnia is a common sleep disorder characterized by difficulty falling asleep, staying asleep, or waking up too early and being unable to return to sleep. Accordingto the International Classification of Sleep Disorders, nsomnia refers to trouble with sleep that is also associated with daytime symptoms (drowsiness, difficulty concentrating), which occurs at least 3x per week for a period of at least 3 months.

This condition impacts 10-50% of the world population at some point in life. It is more often reported by women than men and is much more prevalent in the elderly population.

Why Sleep is Important

Enough sleep is necessary for energy conservation, memory formation, and regulation of the immune system.

• Physical Health: Supports tissue repair, muscle growth, and immune function
• Cognitive Function: Enhances memory, learning, and problem-solving skills
• Emotional Health: Reduces stress and improves mood
• Energy Levels: Ensures you wake up feeling refreshed and ready for the day

Amount of Sleep Needed by Age

• Adults: 7-9 hours
• Newborns: Up to 17 hours
• Children: 9-10 hours
• Teens: 8-10 hours

How Insomnia Affects Your Health

Chronic insomnia has been associated with poorer performance, decreased productivity, and occupational/motor-vehicle accidents. A lack of sleep has even been associated with 7 of the 15 leading causes of death in the United States, including heart disease, diabetes, and high blood pressure.

• Physical Health: Increases the risk of chronic conditions such as heart disease, diabetes, and high blood pressure. It can also lead to weight gain and a weakened immune system.
• Mental Health: Leads to increased stress, anxiety, and depression. It impairs cognitive functions like memory, attention, and decision-making abilities.
• Daily Functioning: Causes fatigue, irritability, and reduced productivity, making it difficult to perform daily tasks effectively

What Does Sleep Have to Do with Epilepsy?

What Causes Insomnia?

Insomnia is a state of "hyperarousal" of the nervous system, where an overactive body or brain keeps you awake. This state can change brain activity, heart rate, and alter hormone levels such as cortisol.

Short-term insomnia (lasting less then 3 months) is often caused by acute, situational triggers, such as sleeping in a new place or dealing with a difficult breakup. Chronic insomnia (lasting more than 3 months) is more often related to longer-lasting issues such as mental health issues, substance use, or behavioural changes.

Some factors that may influence either short-term or long-term insomnia include:

• Family History: Difficulty with sleep often runs in families.
• Mental Health: Mental health conditions are highly linked to insomnia.
• Medical Conditions: Certain health problems, such as acid reflux, restless leg syndrome, and chronic pain, have been associated with difficulty sleeping.
• Life Stressors: Life stressors are common contributors to sleep troubles, especially short-term insomnia. This may include moving to a new house, jet lag, relationship difficulties, and stress at work.

Symptoms of Insomnia

Insomnia symptoms include difficulties with nighttime sleep and daytime functioning.

Difficulty sleeping at night can be categorized into:

• Sleep Onset Insomnia: Difficulty falling asleep.
• Maintenance Insomnia: Difficulty staying asleep, including waking up too early.

Daytime consequences include:

• Fatigue and sleepiness
• Slow reflexes
• Trouble with memory and concentration
• Low mood and irritability

Diagnosis

A diagnosis of chronic insomnia can be made if you experience poor sleep quality and quantity at least 3 nights per week for a minimum of 3 months, and this is not explained by another cause.

To rule out other medical conditions or causes of the difficulty sleeping, your healthcare provider may also perform additional tests such as bloodwork, a physical exam, and/or a sleep study.

While these tests cannot directly diagnose insomnia, they may help identify other diagnoses that could be causing your sleep disruptions.

Lifestyle Changes for Better Sleep

Cognitive Behavioral Therapy for Insomnia (CBT-i)

CBT-i is a specialized form of talk therapy designed to treat insomnia. It focuses on the connection between thoughts and behaviors, helping you identify and change patterns that contribute to sleep difficulties. This evidence-based approach has shown significant, long-term benefits for many individuals.

Good Sleep Hygiene

Sleep hygiene refers to healthy behaviors and habits that promote better sleep. Here are some key recommendations:

• Establish a Schedule: Set consistent bedtime and wake-up times to develop a regular sleep routine.
• Follow a Bedtime Routine: Create a relaxing pre-sleep routine, such as avoiding electronics, practicing mindfulness, and dimming the lights. This can help you fall asleep faster.
• Maintain Healthy Daytime Habits: Your daytime activities impact your sleep. Regular exercise, exposure to sunlight, and limiting alcohol, nicotine, and caffeine intake—especially before bedtime—can enhance sleep quality.

Medication Options for Insomnia

When lifestyle changes aren't enough to manage insomnia, various over-the-counter (OTC) and prescription medications can help. Consult a healthcare provider before starting any new medication to ensure it's safe and appropriate for you.

Over-the-Counter Medications

OTC sleep medications are generally safer but may be less effective, making them suitable for short-term use.

Melatonin (OTC and Prescription)

Melatonin is a hormone that regulates sleep. While your body produces it naturally, synthetic melatonin is available as a supplement. Short-term use can help reduce the time it takes to fall asleep, though its effects on sleep duration and quality are less clear. Melatonin is often recommended first due to its favorable safety profile, with mild side effects like dizziness and headache. Common OTC melatonin products include:

• Nature’s Truth Extra Strength Melatonin Gummies
• Nature’s Truth Fast Dissolve Melatonin
• Natrol Kid’s Melatonin Gummies
• ZzzQuil PURE Zzzs Sleep + Muscle Relaxation Gummies

First-Generation Antihistamines (OTC and Prescription)

These medications, used for allergies and skin reactions, can cause drowsiness and are sometimes used for sleep. However, they are not recommended for long-term use due to significant side effects, especially in older adults, such as dry mouth, urine retention, confusion, and daytime drowsiness. Common first-generation antihistamines include:

• Benadryl (diphenhydramine)
• Unisom (doxylamine)

Prescription Medications for Insomnia

For long-term and more effective management of insomnia, various prescription medications are available. These medications may be particularly suitable for insomnia with specific causes, as they can address multiple factors simultaneously.

Benzodiazepines

Benzodiazepines are used to treat anxiety, seizures, and insomnia by decreasing nervous system activity, leading to sedation. While effective, they carry risks such as daytime drowsiness, confusion, and falls, especially in the elderly.

Long-term use increases the risk of tolerance, dependence, overdose, and withdrawal. Benzodiazepines can also interact dangerously with other nervous system depressants like alcohol and opioids.

Due to these risks, they are controlled substances, available only by prescription. Despite these concerns, they are effective for short-term use. Common benzodiazepines include:

• Ativan (lorazepam)
• Dalmane (flurazepam)
• Doral (quazepam)
• Halcion (triazolam)
• Prosom (estazolam)
• Restoril (temazepam)

Benzodiazepine Receptor Agonists ("Z" Drugs)

"Z drugs" bind to the same receptors as benzodiazepines and are widely prescribed for insomnia. They do not affect anxiety and seizures but share side effects like impaired cognitive performance, risk of falls, and withdrawal symptoms.

They have a lower risk of tolerance and dependence but are approved only for short-term use. Regular monitoring by a healthcare provider is recommended. Common "Z drugs" include:

• Ambien (zolpidem)
• Lunesta (eszopiclone)
• Sonata (zaleplon)

Melatonin Receptor Agonist

Rozerem (ramelteon) is the only melatonin receptor agonist approved for insomnia, specifically for difficulty falling asleep. It is not associated with dependence or withdrawal and is not a controlled substance, making it suitable for long-term use.

Common side effects include dizziness and nausea. It's important to discuss current medications with a healthcare provider due to potential interactions.

Orexin Receptor Antagonists

Orexin Receptor Antagonists (ORAs) are newer medications for insomnia, approved for difficulty falling and/or staying asleep. They block the orexin receptor, which is involved in wakefulness.

Common side effects include daytime drowsiness, with rare but serious effects like sleep paralysis and hallucinations. ORAs are controlled substances but have a favorable safety profile for long-term use. FDA-approved ORAs include:

• Quviviq (daridorexant)
• Belsomra (suvorexant)
• Dayvigo (lemborexant)

Tricyclic Antidepressants

Tricyclic antidepressants (TCAs) are used for various conditions, including insomnia. Silenor (doxepin) is the only TCA approved for insomnia, specifically for difficulty staying asleep. It improves sleep duration without affecting the time to fall asleep.

Side effects are uncommon but may include dizziness, daytime drowsiness, nausea, and high blood pressure. There are also rare but serious risks like reduced alertness and sleep-related hallucinations. Silenor is considered safe and effective for long-term use.