For chronic insomnia, cognitive behavioral therapy for insomnia (CBT-I) is the first-line treatment. The American Academy of Sleep Medicine (AASM) gives it a strong recommendation. A 2025 AASM-commissioned review found CBT-I alone worked best, and adding medication gave only modest extra benefit. Prescription sleep drugs can help some people in the short term. The AASM’s 2017 guideline suggests several of them, but every recommendation is weak. The same guideline suggests against melatonin, valerian, tryptophan, diphenhydramine, and trazodone for chronic insomnia. This page compares each option, then links to a deeper article on each. This is educational information, not medical advice.
Short answer (40-60 words): CBT-I is the first-line treatment for chronic insomnia, with a strong AASM recommendation. Prescription sleep medications can help some people but carry weak recommendations and real side effects. The AASM suggests against melatonin, valerian, diphenhydramine, and trazodone for chronic insomnia. Online programs work best when they follow CBT-I and include human support.
Insomnia Treatment Options at a Glance
| Option | Guideline Stance | Best For | Main Trade-Off |
|---|---|---|---|
| CBT-I (in person or live online) | Strong recommendation, first-line | Chronic insomnia (3+ months) | Takes effort and several weeks |
| Digital CBT-I (apps, programs) | Evidence supports it; human support helps more | People who cannot access a therapist | Fully automated programs show smaller effects |
| Z-drugs and benzodiazepines (zolpidem, eszopiclone, temazepam) | Weak recommendation for short-term use | Short-term relief, with a prescriber | Side effects, tolerance, withdrawal risk |
| Orexin blockers (Belsomra, Dayvigo, Quviviq) | Suvorexant: weak recommendation for sleep maintenance | When CBT-I has not worked | Cost; next-day drowsiness; conflicting data on rare effects |
| Doxepin (low dose) | Weak recommendation for sleep maintenance | Waking during the night | Prescription only |
| Trazodone | Suggests against for insomnia | Insomnia with depression, per a prescriber | Weak evidence outside depression |
| Melatonin | Suggests against for chronic insomnia | Jet lag, shift work, some older adults | Unregulated product quality |
| Diphenhydramine (Benadryl) | Suggests against | Not recommended for regular use | Tolerance; next-day effects |
| Valerian, tryptophan | Suggests against | Not recommended | Weak evidence |
Option 1: CBT-I
CBT-I combines sleep restriction, stimulus control, cognitive work, and relaxation. Research shows large improvements in insomnia severity, and it works when insomnia comes with depression, PTSD, or alcohol use problems. Its benefits tend to last after treatment ends, because it changes the habits that keep insomnia going. Component research shows sleep restriction and stimulus control do most of the work, while sleep hygiene tips alone are weak.
Read more: CBT-I guide and sleep restriction therapy. Sleep restriction is not safe for everyone, so have a trained clinician guide it if you have bipolar disorder, seizures, or a safety-critical job.
Option 2: Online and Digital Programs
Digital CBT-I helps. A meta-analysis of 33 trials found it effective. A 2025 meta-analysis of 29 trials found therapist-supported CBT-I beat fully automated programs. Look for a program that uses real CBT-I methods, offers human support, and screens for red flags first.
Read more: Does online sleep coaching work?
Option 3: Prescription Medication
The 2017 AASM guideline made 14 recommendations. All of them apply to FDA-approved doses in adults, and all compare a drug with no treatment, not with CBT-I. It suggests clinicians use:
- Suvorexant for sleep maintenance
- Eszopiclone and zolpidem for sleep onset and maintenance
- Zaleplon and triazolam for sleep onset
- Temazepam for sleep onset and maintenance
- Ramelteon for sleep onset
- Doxepin for sleep maintenance
Every one of those is a weak recommendation. Weak means the benefits and harms are closely balanced and the choice depends on your situation. Z-drugs carry the FDA’s boxed warning for complex sleep behaviors. See our Ambien side effects guide. Newer orexin blockers work differently. See Belsomra vs. Dayvigo vs. Quviviq. If you already take a sleeping pill and want to stop, read how to stop sleeping pills safely.
Option 4: Trazodone, Melatonin, and Other Common Choices
The same guideline suggests clinicians not use trazodone, diphenhydramine, melatonin, tryptophan, or valerian for chronic insomnia. The reasons differ. Trazodone has limited trial evidence, though it may help people who also have depression. Diphenhydramine builds tolerance quickly. Melatonin produced only small gains in trials, though it has stronger evidence for jet lag and shift work, and some other guidance supports controlled-release melatonin in older adults. A psychiatrist commenting on the guideline noted that sedating antidepressants may suit people with psychiatric conditions, and that only a clinician can decide.
Read more: trazodone, diphenhydramine, and melatonin.
Option 5: Supplements and Gadgets
The AASM guideline did not review most supplements and devices, such as magnesium, CBD, glycine, or sleep gadgets. Our deep dives on these topics found thin direct evidence for insomnia, and many products have quality problems. Treat them as low-evidence extras, not substitutes for a proven treatment.
Option 6: Treat the Underlying Cause
Sometimes the insomnia has a medical driver. Sleep apnea, restless legs, thyroid problems, iron deficiency, depression, pain, and hormone changes all disrupt sleep. A good evaluation checks for these first. See who to see first.
How Do You Choose?
Use this order:
- Rule out red flags. Loud snoring, gasping, heavy daytime sleepiness, or unusual behavior during sleep means see a doctor first.
- Start with CBT-I if your insomnia has lasted three months or longer and you have no red flags. Choose a trained clinician or a structured program with human support.
- Ask about medication if CBT-I is not accessible or has not worked, or if you have another condition that changes the picture. Treat medication as a short-term tool with a review date.
- Use supplements cautiously. Pick products with third-party testing, and tell your doctor what you take.
- Review progress after four to six weeks. If nothing improves, change the plan.
Not sure which path fits you? If you would like to see how we might be able to help you with this deeper, schedule a free consult here.
What the Research Shows
CBT-I is first-line. The AASM gives it a strong recommendation, and a 2025 AASM-commissioned review found it alone worked best.
Every drug recommendation is weak. The 2017 AASM guideline made 14 recommendations, all weak, and all compared a drug with no treatment.
Five common choices carry suggestions against. The guideline suggests against trazodone, diphenhydramine, melatonin, tryptophan, and valerian for chronic insomnia.
Human support improves digital programs. A 2025 meta-analysis of 29 trials found therapist-supported CBT-I outperformed fully automated programs.
This article is for educational purposes only and is not a substitute for personalized medical advice, diagnosis, or treatment.
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When to Seek Professional Help
- Your insomnia has lasted three months or longer
- You snore loudly, gasp, or feel very sleepy during the day
- You use sleeping pills, alcohol, or supplements most nights
- Low mood, anxiety, or thoughts of self-harm come with poor sleep
- You want to start or stop any prescription sleep medication
Frequently Asked Questions
What is the best treatment for chronic insomnia?
CBT-I is the first-line treatment. The AASM gives it a strong recommendation, and a 2025 AASM-commissioned review found CBT-I alone worked best. Medication can help some people, but it adds only modest benefit for a few outcomes.
Are sleeping pills better than CBT-I?
No. Guidelines put CBT-I first. Sleeping pills carry weak recommendations, compare against no treatment in the guideline, and come with side effects and withdrawal risks. CBT-I also tends to last after treatment ends.
Does melatonin work for insomnia?
The AASM suggests against melatonin for chronic insomnia because trial gains were small. It has stronger evidence for jet lag and shift work, and some guidance supports controlled-release melatonin in older adults.
Do natural remedies work for insomnia?
The AASM suggests against valerian and tryptophan, and most other supplements lack strong trial evidence for insomnia. Habit-based approaches such as CBT-I have far better evidence.
How do I know which treatment is right for me?
Check for red flags first, then start with CBT-I if your insomnia is chronic. A doctor can help you decide on medication. If you want help sorting through your options, book a consultation.
When to Work With a Sleep Consultant
There is no single best option for everyone. The strongest evidence points to CBT-I first, medical care when red flags appear, and caution with pills and supplements. If you want help choosing and building a plan, we can help.
