OTC vs Prescription Sleep Aids

Insomnia is a sleep disorder where falling asleep, staying asleep, or getting restful sleep becomes difficult, despite having the chance to rest. It’s more than just the occasional bad night. It leads to next-day problems such as fatigue, low mood, poor concentration, or feeling mentally slowed down.

To be diagnosed as insomnia, these difficulties must occur at least three nights a week and cause noticeable daytime impairment.

Types of Insomnia

Insomnia is classified by duration:

• Episodic: lasts 1–3 months
• Persistent: lasts more than 3 months
• Recurrent: returns at least twice a year

It also comes in different forms:

• Acute insomnia: short-term, often triggered by stress, travel, or life changes
• Primary chronic insomnia: no clear external cause; may involve stress system or circadian rhythm issues
• Associated insomnia: linked to other conditions like anxiety, depression, chronic pain, or medication side effects

What Happens During Sleep?

Sleep cycles between two main phases:

• Non-REM (NREM): Most of the night. It has three stages, each deeper than the last. Brain activity slows, muscles relax, and the body powers down.
• REM (Rapid Eye Movement): Where most dreaming occurs. The brain becomes highly active, while the body remains still. Stress-related systems like the HPA axis and sympathetic nervous system also activate.

Key Brain Chemicals Involved

• GABA: promotes sleep by calming brain activity
• Histamine: promotes wakefulness; levels drop during sleep
• Melatonin: regulates sleep-wake cycles, rising at night
• Serotonin, norepinephrine, acetylcholine, orexin: help regulate sleep-wake cycles

Insomnia affects an estimated 50–70 million adults in the U.S. It’s more common in women and tends to increase with age. Chronic health issues like asthma, pain, or depression can make it worse.

Because causes vary, treatment must be personalized. What works for one person may not work for another, and finding the right approach often takes time.

Over-the-Counter (OTC) Sleep Aids

OTC sleep aids are often used for short-term sleep issues caused by stress, travel, or temporary routine changes. They are not recommended for long-term use and should be used with caution, especially in older adults.

Diphenhydramine (e.g., Benadryl, Nytol)

• Blocks histamine, a chemical that promotes wakefulness, leading to drowsiness.
• Short-term only; not more than 2 weeks in a row.
• Can cause daytime drowsiness, confusion, and memory issues, especially in older adults.
• Generally recommended for those 12 and older.
• Not proven effective for chronic insomnia.

Doxylamine (e.g., Unisom SleepTabs)

• Blocks histamine to promote sedation.
• Short-term; avoid if you can’t get a full night’s sleep.
• May cause next-day grogginess, dizziness, or confusion, especially in adults 65+.
• Avoid if you have glaucoma, breathing issues, or urinary problems (e.g., enlarged prostate).

Melatonin

• Melatonin is a dietary supplement, not a drug.
• Helps regulate the sleep-wake cycle, especially useful for jet lag, shift work, or irregular sleep schedules.
• Best taken under guidance from a healthcare provider.
• Choose products with a USP-verified label for quality assurance.
• Strengths and formulations vary widely.

Common Side Effects

Even though these are OTC products, side effects can occur. Some may be mild and temporary; others may interfere with daily functioning.

• Daytime drowsiness
• Dizziness
• Dry mouth
• Constipation
• Blurred vision
• Trouble concentrating
• Headaches
• Nausea or reduced appetite
• Vivid dreams or nightmares
• Muscle weakness
• Restlessness or jitteriness
• Difficulty urinating
• Hyperactivity (especially in children)
• Bedwetting (mainly with melatonin in children)

Prescription Sleep Medications

Prescription sleep medications are considered when OTC treatments are ineffective or when sleep problems persist. They work through several mechanisms and are selected based on the specific sleep issue; difficulty falling asleep, staying asleep, or both. Most are intended for short-term use due to side effect and dependency risks.

Orexin Receptor Antagonists

• Dayvigo (lemborexant): Helps with falling and staying asleep
• Works by blocking orexin, a brain chemical that promotes wakefulness
• Controlled substance (Schedule IV); take only when you can get at least 7 hours of sleep

Benzodiazepines

These medications slow brain activity to promote relaxation and sleep. They are generally prescribed for short-term use due to the risk of dependence and misuse.

• Estazolam (Prosom): A Schedule IV controlled substance, Estazolam is not typically a first-line treatment for insomnia and is intended for short-term use. Patients should ensure they have 7 to 8 hours available for sleep after taking a dose.
• Triazolam (Halcion): Also a Schedule IV controlled substance, Triazolam is a short-term option to help adults fall asleep, usually prescribed for no more than 7 to 10 days. It carries a risk of dependence and is not for long-term use.

GABA-A Receptor Modulators

• Zolpidem (Ambien): Helps with falling asleep; extended-release forms help with staying asleep.
• Similar to estazolam; fast-acting
• Controlled (Schedule IV); take only if you can sleep 7–8 hours

Melatonin Receptor Agonists

• Ramelteon (Rozerem): Helps with falling asleep
• Mimics melatonin to support natural sleep-wake cycles
• Not a controlled substance; lower risk of dependence

Sedative-Hypnotics

• Zaleplon (Sonata): Helps with falling asleep or middle-of-the-night awakenings. Fast-acting and short-lasting. Controlled (Schedule IV); need 7 hours of sleep after taking.
• Eszopiclone (Lunesta): Helps with both falling and staying asleep. Enhances GABA activity. Controlled (Schedule IV); may cause a bitter taste; allow for a full night’s rest.

Side Effects

Prescription sleep medications vary in how they work and in their side effect profiles. Some cause mild next-day drowsiness; others may lead to more serious effects, especially if not taken as directed.

Common side effects:

• Drowsiness
• Dizziness or lightheadedness
• Headaches
• Nausea or stomach discomfort
• Dry mouth or bad taste
• Unusual dreams or nightmares
• Trouble concentrating or memory issues
• Fatigue or muscle weakness

Less common but serious risks:

• Sleepwalking, sleep-driving, or other activities while not fully awake
• Breathing problems, especially in those with lung conditions
• Hallucinations, confusion, or paranoia
• Worsening anxiety, depression, or mood swings
• Thoughts of self-harm or suicidal behavior
• Allergic reactions (e.g., swelling, rash, difficulty breathing)

ecause of these risks, most prescription sleep aids are not intended for long-term use. Long-term safety is still being studied. One large study found that frequent use (5+ times/month) in older adults was linked to a higher risk of dementia, particularly among White participants.

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Choosing the Right Option

There’s no single solution for insomnia. What works for one person may not work for another. Some people find relief with occasional OTC sleep aids. Others try them and still lie awake for hours.

If sleep problems continue, it’s time to talk with your healthcare provider, not just to get a stronger medication, but to understand what’s causing the issue. It could be stress, pain, a medical condition, or something else interfering with sleep.

Prescription sleep aids can help in certain cases, but they’re not right for everyone. That’s why it’s important to look beyond the sleep symptoms and consider the full picture. The goal is to identify the root cause and choose a treatment that addresses it effectively.