The need to evaluate and treat insomnia depends in large measure on how often sleep is disrupted and on how much insomnia affects daytime functioning. Although treating insomnia on the first visit without further evaluation may be appropriate for patients experiencing grief or other clear acute stressor, severe or long-lasting insomnia mandates a complete workup. This evaluation should focus on underlying medical, neurologic, or psychiatric conditions.

Criteria for the diagnosis of insomnia should include 1 or more of the following symptoms: difficulty falling and staying asleep, poor quality of sleep, difficulty sleeping despite adequate opportunity and circumstances for sleep, and/or awakening too early.  In addition, patients diagnosed with insomnia should have 1 or more of the following types of daytime impairment caused by disturbances in sleep: impairment of attention, concentration, or memory; concerns or anxiety regarding sleep; daytime sleepiness; making errors or having motor crashes or mishaps while working; fatigue or malaise; gastrointestinal symptoms; absent motivation; irritability or disturbances in mood; poor performance in school, at work, or in social settings; and/or tension headaches..

Initial treatment options should include nonpharmacologic therapy, education regarding sleep hygiene, and proper attention to exercise, which has been shown in some trials to improve sleep as effectively as do benzodiazepines. The efficacy of cognitive behavior therapy (CBT) for insomnia is well documented.

When hypnotics are needed, the frequency and duration of use should be individualized based on each patient's specific circumstances. As a general
rule, they should be prescribed only for short periods. Over-the-counter antihistamine preparations should only be used on occasion and not routinely. Because of its potential for abuse, alcohol should not be used to treat insomnia.  Opiates may be helpful for insomnia caused by pain. For short-term treatment, benzodiazepines may be indicated, but long-term use may be associated with adverse effects and withdrawal symptoms. For long-term treatment of chronic insomnia, the newer- generation nonbenzodiazepines, such as zolpidem, zaleplon, eszopiclone, and ramelteon, have a better safety profile are less likely to be abused, and therefore are more effective first-line treatment options.  Melatonin is also effective for short-term use

Over-the-counter antihistamines may be used by nearly one fourth of patients with insomnia, but they generally should be avoided because of poor efficacy and residual drowsiness.

Because of tolerance and an increased risk for dependence and adverse events, barbiturates should be avoided as sleep aids.  Some antidepressants improve total sleep time andsleep quality. However, these antidepressants can suppress rapid eye movement (REM) sleep. Their use should generally be limited to patients with depression and insomnia.  Benzodiazepines are best used for the short-term treatment of insomnia. Tolerance and dependence can occur with prolonged use. Withdrawal occurs in approximately 50% of patients receiving benzodiazepines on a chronic basis.  Nonbenzodiazepine hypnotics, such as zolpidem, zaleplon, and eszopiclone, may have less impact on sleep architecture and may promote less REM sleep rebound compared with benzodiazepines. Therefore, this class of medications may be considered first-line treatments of chronic insomnia.

Medical/Legal Concerns:

Whereas most cases of insomnia are of a non-specific nature, it is essential that chronic cases must be thoroughly evaluated to rule out significant and serious conditions such as sleep apnea and congestive heart failure among others.  Untreated insomnia may result in dangerous conditions that lead to motor vehicle accident, falls etc.