Insomnia and sleep: what works, what does not
Insomnia affects 10–15% of adults and up to 50% of those over 65
Quick answer
The first step for chronic insomnia is CBT-I (cognitive behavioral therapy for insomnia) – it has the strongest RCT evidence and no side effects. Drug options: melatonin 0.3–2 mg works for jet lag and shift work; in primary insomnia the effect is weak. Z-drugs (zolpidem, zopiclone) and benzodiazepines are effective short-term over 2–4 weeks, give tolerance and fall risk in older adults. Among supplements, magnesium 200–400 mg and L-theanine 200 mg showed modest effects in small RCTs; valerian and passionflower have conflicting data; homeopathy and “sleep formula” supplement blends have no confirmation.
The first-line treatment per AASM, NICE and ESRS is not a pill but cognitive behavioral therapy for insomnia (CBT-I). Drug support comes second and depends on the type: sleep onset, sleep maintenance, early awakenings. Melatonin helps in narrow scenarios (jet lag, Delayed Sleep Phase), benzodiazepines and Z-drugs are effective short-term but cause dependence. The supplement category is overhyped in marketing – most valerian and adaptogen formulas do not beat placebo in RCTs.
Prescription hypnotics and sedatives
First- and second-line drugs in insomnia. The effect is RCT-backed, but all carry tolerance risk, daytime sleepiness and interactions with alcohol and opioids. Prescribed short-term over 2–4 weeks, with special caution in older adults (Beers Criteria).
Supplements with weak-to-moderate evidence
Supplements tested in small RCTs. The effect is modest but measurable. Suitable as adjuncts to sleep hygiene and CBT-I.
Herbal agents: conflicting data
Valerian, passionflower, lemon balm, chamomile – popular herbal agents. Cochrane Reviews show conflicting results, the effect is comparable to placebo or slightly above. Used more as ritual than as pharmacologic intervention.
Other drugs in insomnia
- 5-hydroxytryptophan (5-HTP)
- Agomelatine
- Amitriptyline
- Antibodies to S-100 brain-specific protein (homeopathic)
- Apigenin
- Ashwagandha (Withania somnifera)
- Chloropyramine
- Clozapine
- Dimenhydrinate
- Doxylamine/pyridoxine
- Fabomotizole
- Gabapentin
- Gamma-aminobutyric acid (GABA)
- Glycine (as a marketed «nootropic»)
- L-theanine
- L-tryptophan
- Lormetazepam
- Magnesium L-threonate (Magtein)
- Melissa officinalis (leaf extract)
- Olanzapine
- Passionflower (Passiflora incarnata, aerial parts)
- Phenibut
- Pramipexole
- Reishi (Ganoderma lucidum, lingzhi)
- Risperidone
- Ropinirole
- Valeriana officinalis (root extract)
Frequently asked
Does melatonin work for insomnia?
In narrow scenarios. AASM 2021 and Cochrane 2023 confirm melatonin for jet lag (especially eastward travel), shift work and Delayed Sleep Phase Syndrome. In primary chronic insomnia the effect is weak – sleep onset speeds up by 7–10 minutes on average. Doses 0.3–2 mg work better than 5–10 mg. Long-term use looks safe in observational data but needs periodic reassessment.
Can melatonin be combined with prescription hypnotics?
Better not. Melatonin gives a weak sedative effect that adds to CNS depressants (zolpidem, zopiclone, doxylamine, benzodiazepines). In older adults this raises the risk of nighttime falls, morning confusion, orthostatic hypotension. For chronic insomnia, discuss CBT-I and causal reassessment with the prescribing clinician.
Does magnesium help with sleep?
Modestly. A Cochrane-style meta-analysis (Mah & Pitre 2021, 3 RCTs, 151 older patients) showed improved sleep quality and 17 minutes faster sleep onset with magnesium 320–500 mg/day over 8 weeks. Magnesium glycinate and citrate are best studied and best tolerated by the GI tract compared with oxide. The effect is modest but measurable, an adjunct rather than a substitute for CBT-I.
What is worse for sleep – alcohol or Z-drugs?
Both impair sleep, differently. Alcohol shortens sleep onset but fragments REM sleep and causes early awakenings, especially in the second half of the night. Z-drugs (zolpidem, zopiclone) give sleep closer to physiologic, but long-term use brings tolerance, dependence risk and, in older adults, falls and fractures. Combining the two is dangerous (respiratory depression risk, especially in sleep apnea).
How Evigrade helps in insomnia
Most sleep references look at each agent separately. Evigrade scores the regimen as a whole: it computes additive CNS load (benzodiazepine + antihistamine + melatonin + alcohol = fall risk and respiratory depression), interaction with antidepressants (trazodone + SSRI = serotonin syndrome), and Beers Criteria risk in older adults. This covers a real scenario: a patient already takes melatonin and wants to add zopiclone – you need to know what adds up.
Primary sources
AASM Clinical Practice Guideline for Chronic Insomnia 2021, NICE NG147 Insomnia 2024, ESRS European Insomnia Guideline 2023, AEMPS, FDA Drug Label, Cochrane Reviews on melatonin/valerian/magnesium and insomnia, clinical recommendations of the Russian Ministry of Health.