Sleep Disorders (Insomnia): Drug Therapy

Therapeutic target

Restoration of an adequate sleep-wake rhythm.

Therapy recommendations

• Before drug therapy, cognitive behavioral therapy (CBT) should be the first treatment option for adults of any age.
• No drug therapy without prior clarification of the cause (see below chronic pain, depression; medication intake)!
• Sleep-inducing drugs should be prescribed for a maximum of four weeks!
• Taking them for 4-6 nights per month is acceptable.
• Benzodiazepines and benzodiazepine receptor agonists are not agents of first choice for sleep disorders due to potential tolerance and development of dependence; the same applies to sedating antidepressants Attention! If bezodiazepines, then use only short-term, i.e. 2-4 weeks (due todanger of dependence)!
• Non-benzodiazepines (Z-substances; Z-drugs) are agents of first choice for insomnia: Zaleplon, Zolpidem, ZopicloneNote: Early intake of Z-substances in the evening, otherwise with later intake with impairments in the morning is to be expected.FDA Drug Safety Communication: After ingestion of eszopiclone, zaleplon and zolpidem can lead to fatal sleepwalking, i.e. fatal falls and also falls with serious injuries such as intracranial hemorrhage (brain hemorrhage), vertebral body and hip fractures.
• Melatonin is first-line agent in patients with primary insomnia (sleep disorder characterized by the absence of organic or psychiatric disease) aged 55 years and older.
• Antidepressants are used when appropriate for insomnia and depressive disorders.
• Insomnia in neurological disorders [guidelines: S2k guideline].
  • Apoplexy (stroke): benzodiazepine receptor agonists, sedating antidepressants; therapy with real-time light.
  • Epilepsies (seizure disorders): sustained-release melatonin to shorten one sleep latency; preferably use antiepileptic drugs that do not disrupt sleep.
  • Headache: drug therapy (see below headache) in combination with cognitive behavioral therapy (CBT); also melatonin if necessary; further measures: Light therapy
  • Parkinson’s disease: drug therapy (eszopiclone, doxepin, trazodone, ramelteon, zolpidem and melatonin); antipsychotic pimavanserin and antidepressants venlafaxine and nortriptyline should improve subjective sleep quality.
  • Multiple sclerosis (MS): therapy trial with melatonin; further measures: “Cognitive behavioral therapy for insomnia” (CBTi)Note: Corticosteroid therapy usually leads to suppression of melatonin levels and thus to insomnia.
• All the above drugs – except melatonin – affect sleep non-physiologically (“not corresponding to normal life processes”)!
• See also under “Further therapy”.

Phytotherapeutics

Chronic pain, sleep disorders and depression

The symptom cluster “pain, sleep disturbances and depression” is very common. This is not surprising, since the three symptom areas are interrelated. On the one hand, they have overlapping areas, and on the other hand, they reinforce each other:

• Depression and depressive moods are often accompanied by chronic pain.
• Repeated sleep deprivation can relieve depression, but it also increases pain sensitivity.
• Disturbed sleep can thus also be the cause of increased pain sensitivity!
• Chronic pain is associated with a significantly increased prevalence of insomnia, or impaired sleep quality; patients with chronic pain often develop depression

For drug therapy for depression, see “Depression” under Pharmacotherapy. For drug therapy for sleep disorders, see “Sleep disorder” under Pharmacotherapy.

Supplements (dietary supplements; vital substances)

Appropriate dietary supplements should contain the following vital substances:

• L-tryptophan
• Vitamins – D, B1, B2, B3, B5, B6, B12, as well as folic acid and biotin.
• Mineral – magnesium
• Trace element – zinc
• Other vital substances – plant extracts: e.g. valerian root extract, lemon balm extract, sleep berry root extract.

L-tryptophan – from which the human body produces serotonin and the sleep hormone melatonin – is often insufficient as the only vital substance for achieving a peaceful night. Only in combination with the B vitamins and magnesium does it contribute to the normal functioning of the nervous system and to the reduction of tiredness and fatigue, among other things. Zinc contributes to normal cognitive function. Note: The listed vital substances are not a substitute for drug therapy. Dietary supplements are intended to supplement the general diet in a given life situation.