Insomnia Treatment Options Compared: CBT-I, Sleep Medications and What to Try First

For chronic insomnia, the recommended first treatment is cognitive behavioral therapy for insomnia (CBT-I), not a sleeping pill. The American College of Physicians gives CBT-I a strong recommendation as the initial treatment for all adults with chronic insomnia disorder, and the American Academy of Sleep Medicine (AASM) strongly recommends multicomponent CBT-I. Medication is a second step, chosen through shared decision-making when CBT-I alone has not been enough.

When medication is used, the options differ mainly in whether they help you fall asleep, stay asleep or both, and in their risks. The main FDA-approved groups are the "z-drugs" (zolpidem, eszopiclone, zaleplon), the orexin receptor antagonists (suvorexant, lemborexant, daridorexant), low-dose doxepin and ramelteon. Trazodone and melatonin are widely used, but trazodone's FDA approval is for depression, and the AASM suggests against both for chronic insomnia.

Insomnia treatments side by side

Is it chronic insomnia, or something else?

Chronic insomnia means trouble sleeping 3 or more nights a week for more than 3 months that cannot be fully explained by another health problem; short-term insomnia from stress or schedule changes can last days or weeks. The distinction matters because guideline recommendations for CBT-I and medication apply to chronic insomnia disorder.

Before treating insomnia on its own, a clinician should consider conditions that disrupt sleep. Sleep apnea is the most important to rule out. Its signs include loud, frequent snoring, breathing that stops and starts, gasping for air, daytime sleepiness, and in some people insomnia itself, and a sleep study may be needed to diagnose it. Sedating medicines can be a problem with untreated apnea; the doxepin label, for example, says it is ordinarily not recommended in severe sleep apnea. Other contributors worth reviewing include depression and anxiety, pain, restless legs, menopause symptoms, alcohol, caffeine and medicines that interfere with sleep. The guide to sleep study or insomnia treatment explains how to decide which comes first, and medical causes to rule out covers the wider checklist.

CBT-I: why it comes first

CBT-I is a structured, short-term program that changes the habits and thoughts that keep insomnia going. The AASM's 2021 behavioral guideline strongly recommends multicomponent CBT-I and conditionally recommends brief behavioral therapies, stimulus control, sleep restriction therapy and relaxation therapy as single components. It suggests not using sleep hygiene education by itself as a treatment.

The main components are:

• Stimulus control: using the bed only for sleep and sex, and getting up when you cannot sleep, so the bed is re-linked with sleeping.
• Sleep restriction: temporarily limiting time in bed to your actual sleep time, then widening it as sleep consolidates.
• Relaxation training: methods to lower physical and mental arousal at bedtime.
• Cognitive therapy: working on worries about sleep that keep you alert at night.
• Sleep education: timing of caffeine, alcohol, light and exercise, used as part of the package rather than alone.

CBT-I asks more of you than taking a pill. Sleep restriction in particular can make you sleepier for the first weeks, and the program depends on keeping a sleep diary. The benefit is that it treats the patterns maintaining insomnia rather than masking them, and it carries none of the drug risks below. CBT-I is delivered by trained therapists, sleep psychologists, and in digital programs. The practice's article on why CBT-I works describes a typical course.

What a course of CBT-I looks like: a worked example

Consider a hypothetical adult who has had trouble staying asleep most nights for about six months, spends nine hours in bed and sleeps around six. A typical CBT-I plan would unfold like this:

1. Assessment and a sleep diary. For one to two weeks the person records bedtime, time to fall asleep, awakenings and rise time. The clinician also screens for sleep apnea and other causes, since the guideline recommendations assume chronic insomnia disorder.
2. Setting a sleep window. Time in bed is shortened toward the actual sleep time, with a fixed wake time every day. This is sleep restriction therapy, one of the components the AASM recommends.
3. Stimulus control. If awake and frustrated in bed, the person gets up and returns when sleepy.
4. Working on sleep worries. Thoughts such as "if I don't sleep tonight, tomorrow is ruined" are examined and tested.
5. Widening the window. As sleep becomes more efficient, time in bed is gradually extended while keeping the fixed wake time.
6. Relapse planning. The person learns how to respond to a bad patch of nights without returning to old habits.

Most of the work happens at home between sessions, and it helps to expect the first weeks to feel harder because of the shortened sleep window.

Older adults, women and other special situations

Older adults

Older adults are more sensitive to sedating sleep medicines. The zolpidem label recommends 5 mg for geriatric patients of either sex and notes that the elderly are at higher risk of falls; the eszopiclone label likewise calls for a lower dose because of impaired motor and cognitive performance and increased sensitivity. CBT-I avoids these drug risks, and the ACP recommendation of CBT-I as initial treatment applies to all adults.

Women

Zolpidem's recommended starting dose is lower for women than for men because of higher morning blood levels that can impair driving. Insomnia around perimenopause often has its own contributors, such as night sweats; the practice's article on perimenopause insomnia covers them, and perimenopause anxiety treatment options addresses the overlap with anxiety.

People with substance use history

The z-drugs and orexin antagonists are Schedule IV controlled substances, while low-dose doxepin and ramelteon are not controlled. That difference can matter if you have a history of misusing sedatives or alcohol, and it is worth raising with your prescriber.

Sleep medications: what each group does

Z-drugs: zolpidem, eszopiclone, zaleplon

These act on GABA-A receptors like older sedatives. Zolpidem is approved for short-term treatment of trouble falling asleep, with trials of 4 to 5 weeks. Eszopiclone is approved for insomnia and improved both sleep onset and maintenance in trials up to 6 months. Zaleplon is approved for short-term treatment and shortens time to fall asleep, but was not shown to increase total sleep time or reduce awakenings.

In April 2019 the FDA required a boxed warning for all three after rare but serious injuries, including deaths, from sleepwalking, sleep driving and other activities while not fully awake. The agency advised that they not be prescribed to anyone who has had such an episode on any of them. Zolpidem's label recommends a starting dose of 5 mg for women and 5 or 10 mg for men, because higher morning blood levels can impair next-day driving. The zolpidem and suvorexant labels both advise reevaluation if insomnia persists after 7 to 10 days, since it may signal another condition.

Orexin receptor antagonists: suvorexant, lemborexant, daridorexant

These block orexin, a brain signal that promotes wakefulness, rather than sedating the brain broadly. All three are approved for insomnia with difficulty falling asleep, staying asleep, or both. They are Schedule IV controlled substances. Suvorexant's label, for example, lists next-day impairment, worsening depression or suicidal thinking, complex sleep behaviors, and sleep paralysis or hallucinations around sleep among its cautions, and it is contraindicated in narcolepsy. The AASM 2017 guideline suggested suvorexant for sleep maintenance insomnia; lemborexant (first approved in 2019) and daridorexant (2022) came later and were not part of that review.

Low-dose doxepin and ramelteon

Doxepin is an older antidepressant; as Silenor it comes in 3 mg and 6 mg tablets approved for trouble staying asleep, with trials up to 3 months. It is not a controlled substance. Ramelteon acts on melatonin receptors, is approved for trouble falling asleep, and is not a controlled substance. The AASM 2017 guideline suggested doxepin for sleep maintenance and ramelteon for sleep onset.

For a deeper comparison of individual drugs, see sleep medications compared.

Trazodone, melatonin and over-the-counter aids

Trazodone is commonly prescribed for sleep, but its only FDA-approved use is major depressive disorder, so prescribing it for insomnia is off-label. The AASM suggests clinicians not use trazodone for sleep onset or maintenance insomnia, and it carries the antidepressant boxed warning about suicidal thoughts in young people. It may still be considered when insomnia occurs with depression; the comparison in mirtazapine vs trazodone covers that situation.

Melatonin is sold in the US as a dietary supplement, which is regulated less strictly than drugs. The NIH's complementary health center says there is not enough strong evidence on its effectiveness or safety for chronic insomnia, and a 2023 study found 22 of 25 melatonin gummy products were inaccurately labeled: one had no detectable melatonin and the rest contained 74% to 347% of the stated amount. The AASM also suggests against melatonin, diphenhydramine and valerian for chronic insomnia. Melatonin may help with jet lag, a different problem. The practice has a related article on natural remedies for insomnia.

What to try first: a practical sequence

All medication choices, doses and decisions to stop are made with your prescriber. Zolpidem's label, for example, warns that withdrawal symptoms may occur with rapid dose reduction or discontinuation, so ask how to stop. Alcohol adds to the sedation of most sleep medicines; see psychiatric medications and alcohol.

When insomnia and mood problems overlap

Insomnia often occurs alongside depression and anxiety. Several sleep medicine labels warn that worsening depression or suicidal thinking can occur and should be evaluated promptly. If poor sleep comes with low mood, hopelessness or thoughts of self-harm, tell your clinician. If you are thinking about suicide or are in crisis, call or text 988 (the 988 Suicide & Crisis Lifeline) or go to the nearest emergency room. The overview of depression treatment options may help when both are present.

Questions to ask your clinician

• Could sleep apnea, restless legs or another condition explain my sleep problem, and do I need a sleep study?
• Can I get CBT-I, in person or digitally, and how many weeks should I expect?
• If we add a medicine, is it labeled for my problem (falling asleep or staying asleep), and is it a controlled substance?
• What next-day effects should I watch for, especially before driving?
• How long should I take it, and how would we stop?

What the evidence does not show

• Every recommendation for or against an individual sleep medicine in the AASM 2017 guideline is weak, reflecting limited and heterogeneous trials.
• There is little long-term safety evidence for melatonin supplements.
• The AASM suggests against sleep hygiene education as a stand-alone treatment for chronic insomnia.

How this practice approaches insomnia

The practice's ongoing care includes psychiatric evaluation and medication management, psychotherapy including CBT, lab testing, and nutrition and lifestyle psychiatry. You can read its page on sleep disorders and integrative psychiatry and start with the Patient Interest Form. More guides are collected in Choosing Psychiatric Care.

Frequently asked questions

What is the most effective treatment for chronic insomnia?

CBT-I is the recommended first treatment. The American College of Physicians strongly recommends it as initial treatment for all adults with chronic insomnia disorder, and the AASM strongly recommends multicomponent CBT-I.

Are sleeping pills safe to take every night?

It depends on the medicine and the person. Zolpidem and zaleplon are approved for short-term use, while eszopiclone, the orexin antagonists and low-dose doxepin were studied for longer. Your prescriber should review the need regularly.

Is trazodone a good sleep medication?

Trazodone is FDA-approved for depression, not insomnia, and the AASM suggests against using it for chronic insomnia. It is still sometimes prescribed off-label, especially when depression is also present.

Does melatonin work for insomnia?

The evidence for chronic insomnia is not strong, and the AASM suggests against it. Melatonin is a dietary supplement in the US, and product content often differs from the label.

What is the difference between Ambien and Belsomra?

Zolpidem (Ambien) is a z-drug approved for short-term trouble falling asleep and carries a boxed warning for complex sleep behaviors. Suvorexant (Belsomra) is an orexin receptor antagonist approved for trouble falling and/or staying asleep. Both are Schedule IV controlled substances.

Can I do CBT-I online?

Many people use digital or telehealth CBT-I programs. Ask your clinician which format suits you and whether a sleep evaluation is needed first.

Sources

1. Management of Chronic Insomnia Disorder in Adults: A Clinical Practice Guideline From the American College of Physicians. Annals of Internal Medicine (PubMed 27136449), 2016. pubmed.ncbi.nlm.nih.gov
2. Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. Journal of Clinical Sleep Medicine (PubMed 27998379), 2017. pubmed.ncbi.nlm.nih.gov
3. Behavioral and psychological treatments for chronic insomnia disorder in adults: an American Academy of Sleep Medicine clinical practice guideline. Journal of Clinical Sleep Medicine (PubMed 33164742), 2021. pubmed.ncbi.nlm.nih.gov
4. Certain Prescription Insomnia Medicines: New Boxed Warning - Due to Risk of Serious Injuries Caused by Sleepwalking, Sleep Driving and Engaging in Other Activities While Not Fully Awake. U.S. Food and Drug Administration, 2019. fda.gov
5. AMBIEN (zolpidem tartrate) prescribing information. DailyMed / U.S. FDA label, 2025. dailymed.nlm.nih.gov
6. LUNESTA (eszopiclone) prescribing information. DailyMed / U.S. FDA label, 2025. dailymed.nlm.nih.gov
7. Zaleplon capsules prescribing information. DailyMed / U.S. FDA label, 2025. dailymed.nlm.nih.gov
8. BELSOMRA (suvorexant) prescribing information. DailyMed / U.S. FDA label, 2025. dailymed.nlm.nih.gov
9. DAYVIGO (lemborexant) prescribing information. DailyMed / U.S. FDA label, 2025. dailymed.nlm.nih.gov
10. QUVIVIQ (daridorexant) prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
11. SILENOR (doxepin) tablets prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
12. ROZEREM (ramelteon) prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
13. Trazodone hydrochloride tablets prescribing information. DailyMed / U.S. FDA label, 2026. dailymed.nlm.nih.gov
14. Melatonin: What You Need To Know. National Center for Complementary and Integrative Health (NIH), 2024. nccih.nih.gov
15. Sleep Apnea - Symptoms. National Heart, Lung, and Blood Institute (NIH), 2026. nhlbi.nih.gov
16. Insomnia - What Is Insomnia?. National Heart, Lung, and Blood Institute (NIH), 2026. nhlbi.nih.gov

Educational information, not medical, tax or legal advice. Decisions about diagnosis, medication and treatment belong with a clinician who knows your history.