Sleep medicines: what to know

Many people who sleep poorly reach for a pill. Sleep medicines can help for a short time. But they do not fix the reasons you sleep poorly, and some carry real risks. The risks are bigger as you get older.

This page explains the main kinds of sleep medicine, from prescription pills to store-bought sleep aids and melatonin. It covers what each one does, how well it works, and what to watch for. Use it to have a better talk with your doctor or pharmacist.

Try this first: CBT for insomnia

Insomnia means trouble falling asleep, staying asleep, or waking too early, with tiredness during the day. When it lasts for months, it is called chronic insomnia. See Insomnia for more.

The American College of Physicians says every adult with chronic insomnia should be offered cognitive behavioral therapy for insomnia (CBT-I) as the first treatment. CBT-I is a short program that changes the habits and worries that keep insomnia going. The guideline found it helps older adults too.² Strong evidence

The same guideline says a doctor may add medicine if CBT-I alone has not worked. You and your doctor should weigh the benefits, harms and costs together. Most sleep medicines are approved for short-term use, and there is little proof about using them for years.²

You can start CBT-I with our free lessons. See CBT for insomnia and Healthy sleep habits.

How much do sleep pills help?

Less than most people expect. The American Academy of Sleep Medicine (AASM) reviewed the trials of each sleep medicine in 2017. Every recommendation it made, for or against a drug, was rated "weak." Many studies were small, short, or paid for by drug makers.³

In daily life, that often means falling asleep a little faster or sleeping a little longer. It does not usually mean a full, normal night. Ask your doctor what change you should expect, and how you will both know if it is working.

"Suggested" here does not mean safe for everyone. It means the trials showed some benefit over no treatment. Your age, health and other medicines matter a great deal.

Z-drugs: zolpidem, eszopiclone, zaleplon

Z-drugs are the most common prescription sleeping pills. Brand names include Ambien, Lunesta and Sonata. They are sedative-hypnotics, which means they calm the brain to bring on sleep.⁴

In 2019, the FDA added a boxed warning (its strongest kind) to all three drugs. The warning is about complex sleep behaviors. These are things a person does while not fully awake, such as sleepwalking, driving, cooking or making phone calls. People often do not remember them later.¹

The FDA found 66 cases over about 26 years where these acts led to serious injury or death, and 20 people died. Most cases involved zolpidem. The behaviors are rare. But they can happen after the very first dose, even without alcohol.¹

Other risks to know:^1,4

• Next-morning drowsiness. You may be less alert and a worse driver the next day, even if you feel fine.
• Falls. Getting up at night to use the bathroom is a common time to fall.
• Habit and withdrawal. Z-drugs can be habit forming. Stopping suddenly after regular use can cause withdrawal, and rarely seizures.
• Short-term use. They are meant for short periods. After a couple of weeks, many people find they work less well.

MedlinePlus, a National Library of Medicine site, says older adults should not usually take zolpidem, because other options are safer.⁴

Orexin blockers: suvorexant, lemborexant, daridorexant

Orexin is a brain chemical that helps keep you awake. Orexin receptor antagonists (orexin blockers) quiet this wake signal. They work differently from Z-drugs and benzodiazepines. Three are approved in the U.S.:^5,6,7

• Suvorexant (Belsomra), approved in 2014
• Lemborexant (Dayvigo), approved in late 2019
• Daridorexant (Quviviq), approved in 2022

All three are approved for adults who have trouble falling asleep, staying asleep, or both.^5,6,7 Suvorexant has also been studied in people with mild to moderate Alzheimer's disease. In a 4-week study of 285 people, it helped them sleep longer and wake less at night than a placebo (a look-alike pill with no medicine).⁵ See Sleep medicines in dementia.

Their labels list these risks:^5,6,7

• Next-day sleepiness and slower driving, especially with less than a full night in bed
• Sleep paralysis (being briefly unable to move or speak when falling asleep or waking up) and dream-like images
• Short spells of leg weakness
• Complex sleep behaviors, such as sleepwalking
• New or worse depression or thoughts of suicide

People with narcolepsy (a disorder that causes sudden sleep attacks) should not take them. In older adults, drowsiness raises the chance of a fall.^5,6,7

Trazodone

Trazodone is an older antidepressant. Doctors often prescribe it at low doses for sleep, even though it is not FDA-approved for insomnia. This is called "off-label" use, and it is legal and common.

The AASM suggests against using trazodone for chronic insomnia. It found too little good evidence that it helps people fall asleep or stay asleep.³ Limited research If you take it for sleep, ask your doctor why it was chosen and how you will check whether it helps. See Antidepressant medicines.

Low-dose doxepin (Silenor)

Doxepin is a tricyclic-type medicine first approved in 1969 as an antidepressant. A very low-dose tablet (Silenor) is approved for people who have trouble staying asleep. At these doses it acts mainly by blocking histamine, a brain chemical that helps keep you awake.⁸

The AASM gave it weak support for staying asleep.³ Moderate evidence Its label warns about complex sleep behaviors, worse depression, and confusion or over-sedation in older adults. People 65 and older start on a lower dose. It should not be taken with MAO inhibitors (a type of antidepressant), or by people with untreated narrow-angle glaucoma or severe trouble passing urine.⁸ Doxepin is not a controlled substance.⁸

At the higher doses used for depression, doxepin and other tricyclics have stronger anticholinergic effects (they block a brain chemical needed for memory). The sleep tablet uses a much smaller amount.⁸

Melatonin

Melatonin is a hormone your brain makes when it gets dark. It helps set your body clock. In the U.S., melatonin pills and gummies are sold as dietary supplements, which have looser rules than medicines.⁹

Does it help insomnia? The AASM and the American College of Physicians found too little strong evidence to recommend it for chronic insomnia.^3,9 Limited research It may help some body-clock problems, such as jet lag or a very late sleep schedule.⁹ Sleep experts advise against melatonin for people with dementia.⁹

Is it what the label says? Not always. A 2017 study of 31 melatonin products found most did not match their labels, and about 1 in 4 contained serotonin, which was not listed. A 2023 study found 22 of 25 gummy products were mislabeled. Some had almost 3.5 times the stated amount, and one had none.⁹

Safety. Short-term use seems safe for most adults. Long-term safety is not well known. Melatonin can last longer in older adults and cause daytime sleepiness. Ask your doctor first if you take a blood thinner or have epilepsy.⁹ Keep gummies away from children. Thousands of young children have gone to the emergency room after eating melatonin by accident.⁹

Store-bought sleep aids: diphenhydramine

Many "PM" and "nighttime" products contain diphenhydramine. It is the drug in Benadryl, and it is also sold as Nytol and Unisom.¹⁰ Some products mix it with a pain reliever. Doxylamine, another older antihistamine, is in some other sleep aids. Always read the active ingredients.

The AASM suggests against diphenhydramine for chronic insomnia.³ MedlinePlus says people 65 and older should generally not use it, except for serious allergic reactions, because safer options exist.¹⁰

Diphenhydramine is a strong anticholinergic (it blocks a brain chemical needed for memory and other body functions).¹¹ Side effects can include:¹⁰

• Drowsiness and dizziness
• Dry mouth, nose and throat
• Blurry vision or other vision problems
• Trouble passing urine, or pain when you do

Long-term use may also matter for the brain. In a study of about 3,400 adults 65 and older, those who used the most anticholinergic medicine over 10 years were about 1.5 times as likely to develop dementia. Older antihistamines were among the drugs most used. This kind of study shows a link, not proof of cause.¹¹ See Medicines that can worsen memory.

Benzodiazepines

Benzodiazepines include temazepam (Restoril) and triazolam, which are used for sleep.^3,13

In 2020, the FDA required a boxed warning on all benzodiazepines. It covers misuse, addiction, physical dependence and withdrawal.¹² Taking them with opioid pain medicines or other sedating drugs can slow breathing dangerously and can cause death.¹²

For older adults, benzodiazepines raise the risk of falls, daytime sleepiness and memory problems. Doctors usually use lower doses in older people.¹³ The American Geriatrics Society keeps a list of medicines that adults 65 and older should generally avoid, called the Beers Criteria.¹⁴ Ask your doctor whether any of your sleep medicines are on it. See Medicines that can affect mood and memory.

Safer use, especially after 65

If insomnia does not get better within 7 to 10 days on a medicine, your doctor should look for another cause, such as depression, pain, or sleep apnea.^2,6 See Sleep apnea, Sleep, mood and anxiety and Sleep in later life.

Questions to ask your doctor

Do I need a sleep medicine at all?

• Could CBT-I work for me first? Where can I get it?
• Could another health problem, pain or medicine be causing my poor sleep?

If I take one, which is safest for me?

• How does it fit with my age, my other medicines and my health?
• What side effects should I watch for? Could it raise my risk of falling?
• How long should I take it, and how will we decide to stop?

What about store-bought products?

• Is it safe for me to use a "PM" sleep aid or melatonin?
• Do any of my other medicines contain diphenhydramine?

When to get help

• Call 911 if someone on a sleep medicine is very hard to wake, is breathing slowly, or was hurt during sleepwalking or sleep driving.
• Call your doctor soon if you do things at night you do not remember, feel groggy most mornings, fall, or feel more confused.
• Call or text 988 if you have thoughts of suicide or feel your mood getting worse. Some sleep medicines can worsen depression.^5,8 Help is free and open day and night.

Education only. This page is general information written from the sources listed. It is not medical, legal or financial advice and does not replace a doctor, therapist or lawyer who knows your situation. How we write and check pages.