The Complete Guide to Insomnia Treatment
Evidence-based approaches to understanding, diagnosing, and treating insomnia. From CBT-I to medication options, learn what actually works from a Stanford-trained sleep specialist.
What Is Insomnia?
Insomnia is a sleep disorder characterized by persistent difficulty falling asleep, staying asleep, or experiencing non-restorative sleep despite adequate opportunity for sleep. It's the most common sleep disorder, affecting 10-30% of adults at any given time.
Insomnia is not just "having trouble sleeping." It's a clinical condition that causes significant daytime impairment - fatigue, mood disturbances, difficulty concentrating, and reduced quality of life. The diagnosis requires both nighttime sleep difficulties AND daytime consequences.
Key Diagnostic Criteria
According to the International Classification of Sleep Disorders (ICSD-3), chronic insomnia requires: (1) Sleep difficulty ≥3 nights per week, (2) Duration ≥3 months, (3) Adequate sleep opportunity, and (4) Daytime impairment (fatigue, mood problems, cognitive dysfunction).
Types of Insomnia
Acute Insomnia
Short-term insomnia lasting days to weeks, typically triggered by stress, life changes, or acute medical conditions.
Common Triggers:
- Job stress or work deadlines
- Relationship problems
- Travel or time zone changes
- Acute illness or hospitalization
- Grief or loss
Chronic Insomnia
Long-term insomnia persisting ≥3 months, occurring ≥3 nights per week. Often develops from acute insomnia through behavioral conditioning.
Perpetuating Factors:
- Anxiety about sleep
- Irregular sleep schedules
- Prolonged time in bed awake
- Compensatory behaviors (napping, sleeping in)
- Hyperarousal (physical/cognitive)
Sleep-Onset Insomnia
Difficulty falling asleep initially (taking >30 minutes to fall asleep). Often associated with anxiety, racing thoughts, or delayed sleep phase.
Sleep-Maintenance Insomnia
Frequent nighttime awakenings or early morning awakening with inability to return to sleep. Common in depression and sleep apnea.
Common Causes of Insomnia
Psychological Factors
Stress & Anxiety:
Work stress, financial worries, relationship problems, or general anxiety activate the body's stress response (elevated cortisol, increased heart rate), making sleep difficult.
Depression:
75% of people with depression have insomnia. Early morning awakening is particularly common. Insomnia can also increase depression risk.
Medical Conditions
- Sleep Apnea (COMISA): 30-50% of insomnia patients also have sleep apnea. Breathing interruptions cause awakenings.
- Chronic Pain: Arthritis, fibromyalgia, back pain make comfortable sleep difficult.
- GERD: Acid reflux worsens when lying down, causing nighttime awakenings.
- Thyroid Disorders: Hyperthyroidism causes hyperarousal; hypothyroidism causes fatigue but poor sleep quality.
- Restless Legs Syndrome: Uncomfortable leg sensations delay sleep onset.
- Menopause: Hot flashes and hormonal changes disrupt sleep in 40-60% of women.
Lifestyle & Behavioral Factors
Poor Sleep Hygiene:
- Irregular sleep schedule
- Screen time before bed
- Bedroom too warm/bright/noisy
- Using bed for non-sleep activities
Substance Use:
- Caffeine after 2 PM
- Alcohol (disrupts REM sleep)
- Nicotine (stimulant)
- Recreational drugs
Work Factors:
- Shift work
- On-call schedules
- Frequent time zone travel
- High-stress occupations
Symptoms & Diagnosis
Nighttime Symptoms:
- Taking >30 minutes to fall asleep
- Waking frequently during the night
- Waking too early (3-5 AM)
- Non-restorative sleep
- Anxiety when trying to sleep
- Racing thoughts or worry
Daytime Symptoms:
- Fatigue or low energy
- Difficulty concentrating
- Memory problems
- Mood disturbances (irritability, anxiety)
- Impaired work/school performance
- Increased errors or accidents
When Sleep Testing Is Needed
Most insomnia is diagnosed clinically without a sleep study. However, sleep testing is recommended if you have:
- Loud snoring, gasping, or witnessed breathing pauses (possible sleep apnea)
- Excessive daytime sleepiness despite adequate sleep opportunity
- Uncomfortable leg sensations preventing sleep (possible RLS)
- Insomnia that doesn't respond to CBT-I or medication
CBT-I: The Gold Standard Treatment
Cognitive Behavioral Therapy for Insomnia (CBT-I) is the first-line treatment for chronic insomnia recommended by the American Academy of Sleep Medicine. It's more effective long-term than medication, with 70-80% of patients experiencing significant improvement.
CBT-I addresses the thoughts, behaviors, and physiological arousal that perpetuate insomnia. Effects are lasting - improvements persist years after treatment ends.
Core Components of CBT-I:
1. Sleep Restriction Therapy
Temporarily limit time in bed to match actual sleep time, building sleep pressure and improving sleep efficiency. As sleep consolidates, time in bed gradually increases.
Example: If you sleep 5 hours but spend 8 hours in bed, restrict to 5.5 hours initially. This creates stronger sleep drive.
2. Stimulus Control Therapy
Re-associate bed with sleep, not wakefulness. Key rules:
- Go to bed only when sleepy
- Use bed only for sleep (and intimacy)
- If not asleep within 20 minutes, leave bedroom
- Return to bed only when sleepy again
- Wake at same time every morning
- No daytime napping
3. Cognitive Therapy
Address unhelpful thoughts and beliefs about sleep:
4. Sleep Hygiene Education
Optimize environmental and behavioral factors:
- Keep bedroom cool (65-68°F)
- Block light with blackout curtains
- Use white noise if needed
- Limit caffeine after 2 PM
- Avoid alcohol 3+ hours before bed
- No screens 30-60 min before bed
- Exercise regularly (not close to bedtime)
- Create wind-down routine
5. Relaxation Techniques
Reduce physiological and cognitive arousal:
- Progressive muscle relaxation
- Diaphragmatic breathing
- Mindfulness meditation
- Guided imagery
CBT-I Delivery Options:
In-Person Therapy
Most effective. 4-8 weekly sessions with sleep specialist. Learn about our CBT-I program.
Telehealth CBT-I
Video-based therapy. Equally effective as in-person for most patients. Convenient for busy schedules.
Digital CBT-I
App-based programs (Sleepio, Somryst). Lower cost, self-paced. Less effective than therapist-guided treatment.
Medication Options for Insomnia
Important: Medications are second-line treatment after CBT-I. They can provide short-term relief but don't address underlying causes. Many lose effectiveness over time and carry risks of tolerance, dependency, and side effects. Always use under physician supervision.
FDA-Approved Prescription Medications:
Benzodiazepine Receptor Agonists (Z-Drugs):
Zolpidem (Ambien), Eszopiclone (Lunesta), Zaleplon (Sonata). Work quickly but carry risks of tolerance, dependency, next-day impairment, and complex sleep behaviors.
Best for: Short-term use (<2-4 weeks) during acute stress or while starting CBT-I.
Orexin Receptor Antagonists:
Suvorexant (Belsomra), Lemborexant (Dayvigo). Block wakefulness signals. Lower abuse potential than Z-drugs but can cause next-day drowsiness.
Best for: Sleep-maintenance insomnia, patients with substance use history.
Melatonin Receptor Agonists:
Ramelteon (Rozerem), Tasimelteon (Hetlioz). Promote sleep onset by mimicking melatonin. Non-habit forming but weaker than other options.
Best for: Sleep-onset insomnia, circadian rhythm disorders, elderly patients.
Low-Dose Doxepin:
Silenor (3-6 mg). Antihistamine effects improve sleep maintenance. Approved for sleep-maintenance insomnia.
Best for: Middle-of-night or early morning awakenings.
Over-the-Counter & Supplements:
Melatonin (0.5-5 mg):
Helps sleep onset, especially for circadian rhythm issues. Most effective for jet lag and delayed sleep phase. Take 1-2 hours before bedtime. Not regulated by FDA.
Antihistamines (Diphenhydramine, Doxylamine):
Found in Benadryl, Unisom. Cause drowsiness but lose effectiveness within days. Side effects: next-day grogginess, dry mouth, cognitive impairment in elderly.
Magnesium:
May help sleep quality in deficient individuals. Limited evidence. Try 200-400 mg magnesium glycinate 1-2 hours before bed.
Medications to Avoid for Sleep
- Benzodiazepines (Xanax, Ativan, Valium) - High addiction risk, cognitive impairment, withdrawal issues
- Alcohol - Disrupts sleep architecture, worsens sleep apnea, causes rebound insomnia
- Cannabis/CBD - Limited evidence, tolerance develops, REM suppression, next-day impairment
Lifestyle Interventions That Work
Exercise
Regular exercise improves sleep quality and reduces time to fall asleep. Aim for 150 minutes/week of moderate activity. Avoid vigorous exercise within 3 hours of bedtime.
Best timing: Morning or afternoon exercise most beneficial.
Light Exposure
Get 30+ minutes of bright light exposure in morning to strengthen circadian rhythms. Dim lights 2-3 hours before bed. Use blue-light blocking glasses or software if evening screen use is necessary.
Diet
Avoid large meals within 3 hours of bedtime. Limit fluids 2 hours before bed to reduce nighttime awakenings. Small protein-rich snack (e.g., almonds, turkey) can prevent hunger-related awakenings.
Stress Management
Practice stress-reduction techniques: meditation, yoga, journaling, therapy. Schedule "worry time" earlier in day (not before bed). Consider mindfulness-based stress reduction (MBSR) programs.
When to See a Sleep Doctor
See a board-certified sleep medicine physician if:
- Insomnia persists >3 weeks despite good sleep hygiene
- Daytime functioning is significantly impaired
- You suspect sleep apnea (snoring, gasping, breathing pauses)
- You experience uncomfortable leg sensations preventing sleep
- You're considering sleep medication
- Insomnia co-occurs with depression or anxiety
- Self-help strategies and OTC remedies haven't worked
- You want professional CBT-I guidance
Frequently Asked Questions
Common Questions about Insomnia Treatment
Get Expert Help for Your Insomnia
Dr. Vikas Jain is a Stanford-trained, board-certified sleep medicine physician specializing in evidence-based insomnia treatment including CBT-I. Serving Dallas, Frisco, Plano, and North Texas.