• Luigi Ferini-Strambi.
• Sleep Disorders Center, Vita-Salute San Raffaele University, Milan, Italy - ferinistrambi.luigi@hsr.it.
• Minerva Med. 2025 Feb 11.

AbstractInsomnia is a prevalent public health issue, characterized by dissatisfaction with the duration, continuity, and quality of sleep. It is closely associated with daytime symptoms, which are essential for diagnosing insomnia disorder. The condition is more common among women, middle-aged and older adults, and individuals with coexisting mental or physical health conditions. Evidence suggests that insomnia increases the risk of various health problems. Addressing insomnia is therefore crucial not only to enhance patients' quality of life but also to mitigate its significant health, social, and economic impacts. However, further studies are needed to evaluate the cost-effectiveness of insomnia treatments. Cognitive behavioral therapy for insomnia (CBT-I) is recommended as the first-line treatment for chronic insomnia in adults. When CBT-I proves ineffective or is unavailable, pharmacological treatments may be considered. Benzodiazepines (BZs) and benzodiazepine receptor agonists (BZRAs) are suitable for short-term treatment (up to 4 weeks). Among BZs, triazolam is notable for its short half-life and demonstrated efficacy in treating sleep-onset and middle-of-the-night (MOTN) insomnia, supported by robust clinical evidence. Additionally, triazolam does not impair psychomotor performance. In certain cases, longer-term use of BZs or BZRAs may be appropriate; however, this approach requires careful individual assessment of the benefits and risks. Non-nightly use of hypnotic medications may also be a viable option for patients who do not require nightly treatment. Low-dose sedating antidepressants may be considered for short-term insomnia management (off-label), while antipsychotics and antihistamines are not recommended for this purpose. Orexin receptor antagonists are an option for treating insomnia for up to three months. It is important to note that although insomnia guidelines are based on daily use as evaluated in randomized controlled trials, clinical practice may vary.

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