Different Treatment Approaches
The different treatment approaches to insomnia are based on the relationship between the neurophysiological mechanisms that promote wakefulness versus sleep. The sleep versus wake cycle is determined by coordinated activity between the sleep-promoting system and the wake-promoting system of the brain. Each system has chemical messengers (neurotransmitters). The sleep-promoting neurotransmitters include gamma-amino-butyric acid (GABA) and galanin. The wake-promoting neurotransmitters are histamine, orexin, norepinephrine, and serotonin. Both groups of neurotransmitters influence the sleep state and dysfunction in either system can contribute to insomnia.
Benzodiazepine Hypnotic Agents
The most commonly used treatments for insomnia are the benzodiazepine receptor agonists. These medications affect the sleep-promoting system, by enhancing the activity of GABA, the inhibitory neurotransmitter in the body. Binding to GABA to receptors inhibits neurons in the brain that maintain wakefulness.
This group of medications consists of traditional benzodiazepines and nonbenzodiazepine agonists. Traditional benzodiazepines have sedative, anti-anxiety, muscle relaxant, and anticonvulsant properties. Nonbenzodiazepine agonists have only sedative properties. Benzodiazepines relieve insomnia by reducing sleep latency and increasing total sleep time.
The benzodiazepine agents that are used for insomnia are temazepam (Restoril) 7.5 mg to 30 mg and Estazolam (Prosom) 1 to 2 mg. Both agents are taken before bedtime. Factors including symptom pattern, sleep history, cost, and preference can help select a specific medication.