Insomnia: what should you try before sleeping pills?
What really works for chronic insomnia before reaching for pills, and what to know if you already take some.
In short
- The 2023 European insomnia guideline recommends cognitive behavioural therapy for insomnia (CBT-I) as the first treatment for chronic insomnia in adults of any age.
- Reviewing your routine, caffeine, alcohol, screens and the medication you already take can explain part of the problem.
- Sleeping pills (benzodiazepines and "Z-drugs") are for short periods: generally no more than four weeks.
- Sedating antihistamines and herbal products are not recommended for treating insomnia, according to the same guideline.
Before turning to sleeping pills, the treatment with the strongest evidence for chronic insomnia is cognitive behavioural therapy for insomnia (CBT-I). The 2023 European insomnia guideline, produced by the European Sleep Research Society, recommends it as the first treatment for adults of any age, including people with other conditions, either face to face or through validated digital programmes.
Pills can help at particular moments, but they do not solve the cause and long-term use carries risks. Here is what you can try, what to check in your own medication and when to ask for help.
According to the European guideline, insomnia is chronic when you find it hard to get to sleep, stay asleep or you wake too early at least three nights a week for three months or more, and it affects you during the day. If it lasts weeks, talk to your GP: sometimes there is another treatable problem behind it, such as sleep apnoea, pain, anxiety or depression.
| What will you find in this article? |
What is cognitive behavioural therapy for insomnia?
CBT-I is a structured treatment lasting several weeks that changes the habits and thoughts that keep insomnia going. It is not just "sleep hygiene": it combines several techniques that a professional tailors to you.
| Technique | What it involves |
|---|---|
| Stimulus control | Using the bed only for sleep and getting up if you do not fall asleep after a while |
| Sleep restriction | Matching your time in bed to the time you actually sleep, to consolidate sleep |
| Cognitive restructuring | Changing anxious thoughts such as "if I do not sleep 8 hours, tomorrow will be awful" |
| Relaxation | Techniques to wind down before bed |
| Sleep habits education | Regular times, caffeine, alcohol, exercise, light and screens |
Ask at your health centre whether they have groups or psychologists who offer it. The European guideline also accepts digital versions with proven effectiveness, preferably guided.
Which habits can I change from tonight?
Some simple changes can improve your sleep or at least stop it getting worse. MedlinePlus notes that changing your sleep habits can improve or solve insomnia.
- Go to bed and get up at the same time, at weekends too.
- Avoid long naps, and if you nap, keep it short and early.
- Cut down on caffeine from mid-afternoon and do not use alcohol to sleep: it fragments sleep.
- Keep your phone, tablet and TV out of bed.
- Exercise every day, but not right before bed.
- If you have been lying awake for a long while, get up, do something calm in dim light and go back when you feel sleepy.
Could my medication be keeping me awake?
Yes, sometimes. Some cold remedies, other prescription or over-the-counter medicines, herbs and supplements can disturb sleep, according to MedlinePlus. When you take each tablet also matters: a diuretic at night, for example, can have you getting up to the toilet.
If you take several medicines, ask your pharmacist to check whether any of them could be affecting your rest and whether the time of a dose should change. Never change or stop a treatment on your own.
What if I already take sleeping pills?
Benzodiazepines (such as lorazepam) and "Z-drugs" (such as zolpidem) are useful in the short term, but the body gets used to them and they can cause dependence. The zolpidem leaflet says that in most cases treatment should not exceed two weeks, with a maximum of four including gradual withdrawal. The European guideline also generally reserves them for short courses of four weeks or less.
They can also cause next-day drowsiness, affect driving and increase the risk of falls. If you have taken them for a long time, do not stop suddenly: talk to your doctor about planning a gradual withdrawal while you start CBT-I. You can read more about driving and medicines and medicines that increase the risk of falls.
Be careful with over-the-counter products too: the European guideline does not recommend antihistamines, fast-release melatonin or herbal remedies for treating insomnia. Prolonged-release melatonin is considered for people aged 55 and over for up to three months.
A practical example: Elena and her sleepless nights
Take the case of Elena, 61, a teacher with high blood pressure and an underactive thyroid. For five months she has been waking at four in the morning and not getting back to sleep. A friend offers her "a little pill" that works for her.
Elena says no and books an appointment with her GP. Beforehand, she keeps a diary for two weeks: what time she goes to bed, how long it takes to fall asleep, when she wakes up, how much coffee she drinks and when she takes each medicine. At the appointment they realise she takes her diuretic at night and spends nine hours in bed although she sleeps six.
Her GP changes the time of the diuretic and refers her to a CBT-I group at the health centre. Within a few weeks, Elena is sleeping more soundly without adding any pills.
How can IMA Health help you?
Having your medication arranged by time helps each tablet be taken at the right moment of the day, which affects how you sleep. At IMA Health we coordinate with a specialised pharmacy that prepares your medication by day and time of each dose, we deliver it to your home and we provide personalised follow-up, so any change your doctor makes is reflected without mistakes.
Sources
- Riemann D. et al. The European Insomnia Guideline 2023. Journal of Sleep Research
- CIMA (AEMPS): leaflet for Zolpidem Cinfa 10 mg (in Spanish)
- CIMA (AEMPS): leaflet for Lorazepam Cinfa 1 mg (in Spanish)
- MedlinePlus: Insomnia
This article is for information only and does not replace advice from your doctor or pharmacist.