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DRAFT - Pending Review
This plan requires physician review before clinical use.

Insomnia — Neurological Approach

VERSION: 1.0 CREATED: February 7, 2026 REVISED: February 7, 2026 STATUS: Draft


DIAGNOSIS: Insomnia — Neurological Approach

ICD-10: G47.00 (Insomnia, unspecified), G47.01 (Insomnia due to medical condition), F51.01 (Primary insomnia)

CPT CODES: 95810 (Polysomnography (PSG)), 95803 (Actigraphy), 85025 (CBC), 80053 (CMP), 84443 (TSH), 82728 (Serum ferritin), 82533 (Cortisol), 96132 (Neurocognitive testing), 80307 (Urine drug screen), 82607 (Vitamin B12), 82746 (Folic acid), 84402 (Testosterone, free), 83036 (HbA1c), 86140 (CRP), 85652 (ESR), 95819 (EEG awake and sleep), 70553 (MRI brain with and without contrast)

SYNONYMS: Insomnia, chronic insomnia, sleep onset insomnia, sleep maintenance insomnia, terminal insomnia, early morning awakening, neurological insomnia, comorbid insomnia, psychophysiological insomnia, conditioned insomnia, paradoxical insomnia, insomnia disorder, sleep-onset difficulty, nonrestorative sleep

SCOPE: Neurological evaluation and management of insomnia in adults with neurological conditions. Focuses on insomnia comorbid with TBI, dementia, MS, Parkinson's disease, chronic pain, epilepsy, and stroke. Covers CBT-I as first-line, pharmacotherapy selection considering neurological comorbidities, and identification of secondary causes. Excludes primary psychiatric insomnia management (though addresses overlap), circadian rhythm disorders as primary diagnosis, and pediatric insomnia.


DEFINITIONS: - Insomnia Disorder: Dissatisfaction with sleep quantity or quality associated with difficulty initiating sleep, maintaining sleep, or early morning awakening, occurring at least 3 nights per week for at least 3 months, causing clinically significant distress or functional impairment, and not better explained by another sleep-wake disorder - Chronic Insomnia: Insomnia symptoms persisting for 3 months or longer; previously termed "primary insomnia" when no identifiable comorbidity was present - Sleep Onset Insomnia: Difficulty falling asleep at the beginning of the sleep period; sleep onset latency >30 minutes in adults - Sleep Maintenance Insomnia: Difficulty staying asleep with prolonged awakenings during the night; wake after sleep onset (WASO) >30 minutes - Terminal Insomnia (Early Morning Awakening): Waking earlier than desired with inability to return to sleep; often associated with depression and neurodegenerative disease - Comorbid Insomnia: Insomnia occurring in the context of another medical, neurological, or psychiatric condition; the current preferred terminology over "secondary insomnia" - Psychophysiological Insomnia: Conditioned arousal and learned sleep-preventing associations; the patient becomes anxious about not sleeping, which perpetuates the insomnia - Sleep Efficiency: Ratio of total sleep time to time spent in bed, expressed as a percentage; normal >85% - Insomnia Severity Index (ISI): Validated 7-item self-report measure; scores 0-7 (no insomnia), 8-14 (subthreshold), 15-21 (moderate), 22-28 (severe)


DIAGNOSTIC CRITERIA (ICSD-3-TR / DSM-5-TR):

Insomnia Disorder — All of the following:

  1. The patient reports, or the patient's parent or caregiver observes, one or more of the following:
    • Difficulty initiating sleep
    • Difficulty maintaining sleep
    • Waking up earlier than desired
    • Resistance to going to bed on appropriate schedule
    • Difficulty sleeping without parent or caregiver intervention
  2. The patient reports, or the patient's parent or caregiver observes, one or more of the following related to the nighttime sleep difficulty:
    • Fatigue/malaise
    • Attention, concentration, or memory impairment
    • Impaired social, family, vocational, or academic performance
    • Mood disturbance/irritability
    • Daytime sleepiness
    • Behavioral problems (hyperactivity, impulsivity, aggression)
    • Reduced motivation/energy/initiative
    • Proneness for errors/accidents
    • Concerns about or dissatisfaction with sleep
  3. The reported sleep/wake complaints cannot be explained purely by inadequate opportunity or circumstances for sleep
  4. The sleep disturbance and associated daytime symptoms occur at least 3 times per week
  5. The sleep disturbance and associated daytime symptoms have been present for at least 3 months
  6. The sleep/wake difficulty is not better explained by another sleep disorder

Insomnia Severity Index (ISI) Interpretation: - No clinically significant insomnia: 0-7 - Subthreshold insomnia: 8-14 - Moderate insomnia: 15-21 - Severe insomnia: 22-28

Pittsburgh Sleep Quality Index (PSQI) Interpretation: - Good sleep quality: 0-4 - Poor sleep quality: >=5 (global score)


PRIORITY KEY: STAT = Immediate | URGENT = Within hours | ROUTINE = Standard | EXT = Extended/atypical cases | - = Not applicable to this setting


1. LABORATORY WORKUP

1A. Essential/Core Labs (All Patients)

Test Rationale Target Finding ED HOSP OPD ICU
CBC (CPT 85025) Exclude anemia contributing to fatigue and sleep disruption Normal ROUTINE ROUTINE ROUTINE -
CMP (CPT 80053) Electrolyte abnormalities, renal/hepatic function; pre-treatment baseline Normal ROUTINE ROUTINE ROUTINE -
TSH (CPT 84443) Hypothyroidism causes fatigue and hypersomnia; hyperthyroidism causes insomnia and anxiety Normal (0.5-4.5 mIU/L) ROUTINE ROUTINE ROUTINE -
Serum ferritin (CPT 82728) Iron deficiency screen; low ferritin (<50 ng/mL) associated with restless legs syndrome causing sleep-onset and maintenance insomnia >50 ng/mL - ROUTINE ROUTINE -
AM cortisol (CPT 82533) Screen for adrenal dysfunction; elevated cortisol causes insomnia; Cushing syndrome; HPA axis dysregulation in chronic insomnia Normal AM cortisol (6-18 mcg/dL) - ROUTINE ROUTINE -
Urine drug screen (CPT 80307) Exclude stimulant use, substance-related insomnia; caffeine, amphetamines, cocaine Negative URGENT ROUTINE ROUTINE -

1B. Extended Workup (Second-line)

Test Rationale Target Finding ED HOSP OPD ICU
Vitamin B12 (CPT 82607) Deficiency associated with neuropathy, RLS, and sleep disruption >400 pg/mL - ROUTINE ROUTINE -
Folic acid (CPT 82746) Deficiency contributes to fatigue and neuropsychiatric symptoms >4 ng/mL - ROUTINE ROUTINE -
Testosterone, free (CPT 84402) Low testosterone in men associated with fatigue, poor sleep, and reduced sleep quality Normal for age and sex - - EXT -
Melatonin level (serum or salivary) Assess dim light melatonin onset (DLMO) in suspected circadian component; low endogenous melatonin in elderly Document; correlate with timing - - EXT -
HbA1c (CPT 83036) Diabetes screening; neuropathic pain disrupts sleep; poorly controlled diabetes associated with insomnia <5.7% - ROUTINE ROUTINE -
ESR (CPT 85652) / CRP (CPT 86140) Screen for inflammatory or autoimmune conditions contributing to pain-related insomnia Normal - ROUTINE ROUTINE -

1C. Rare/Specialized

Test Rationale Target Finding ED HOSP OPD ICU
Polysomnographic biomarkers (sleep microstructure analysis) Research-level assessment of sleep architecture disruption; cyclic alternating pattern (CAP) rate Document; correlate with clinical findings - - EXT -
HLA-DQB1*06:02 typing (CPT 81383) If narcolepsy or central hypersomnolence is suspected in the differential Document; supportive of narcolepsy if positive - - EXT -
CSF orexin / hypocretin-1 If narcolepsy is suspected; rule out central hypersomnolence disorder >200 pg/mL normal; <=110 pg/mL suggests narcolepsy type 1 - EXT EXT -

2. DIAGNOSTIC IMAGING & STUDIES

2A. Essential/First-line

Study Timing Target Finding Contraindications ED HOSP OPD ICU
Sleep diary (minimum 2 weeks) Before any intervention; ongoing during treatment Document sleep onset latency, WASO, total sleep time, sleep efficiency; identify patterns and contributing factors None ROUTINE ROUTINE -
Actigraphy (CPT 95803) (2 weeks) Objective assessment of sleep-wake patterns; pre-treatment baseline Confirm sleep diary; identify circadian pattern disruption; estimate total sleep time and sleep efficiency None - ROUTINE -
Insomnia Severity Index (ISI) Each visit; validated outcome measure Baseline severity and treatment response; target ISI <8 (remission) None ROUTINE ROUTINE -
Pittsburgh Sleep Quality Index (PSQI) Baseline and q3 months Global sleep quality assessment; PSQI >5 indicates poor sleep quality None - ROUTINE -
Epworth Sleepiness Scale (ESS) Baseline to screen for excessive daytime sleepiness suggesting comorbid sleep disorder ESS <=10 (normal); elevated ESS suggests OSA, narcolepsy, or other hypersomnia None ROUTINE ROUTINE -

2B. Extended

Study Timing Target Finding Contraindications ED HOSP OPD ICU
Polysomnography (PSG) (CPT 95810) If comorbid sleep disorder suspected (OSA, PLMD, RBD, nocturnal seizures); NOT for uncomplicated insomnia Exclude OSA (AHI >5), PLMD (PLMS >15/hr), RBD, nocturnal seizures; document sleep architecture None - ROUTINE ROUTINE -
EEG (awake and sleep) (CPT 95819) If nocturnal seizures or epileptiform activity suspected Epileptiform discharges; focal slowing; sleep-related epilepsy patterns None - ROUTINE EXT -
MRI brain with and without contrast (CPT 70553) If structural cause suspected (TBI sequelae, hypothalamic lesion, neurodegenerative disease) Rule out structural lesion, white matter disease, thalamic/hypothalamic pathology Per standard MRI contraindications - ROUTINE EXT -

2C. Rare/Specialized

Study Timing Target Finding Contraindications ED HOSP OPD ICU
Home sleep testing (HSAT) If obstructive sleep apnea is suspected as contributing factor but in-lab PSG not feasible AHI assessment; screen for moderate-severe OSA Cannot diagnose central apnea, PLMD, or RBD - - EXT -
Advanced circadian rhythm testing (DLMO, core body temperature rhythm) If circadian rhythm component suspected Document phase delay or advance; correlate with actigraphy and sleep diary None - - EXT -
Cognitive behavioral assessment (neurocognitive testing) (CPT 96132) If significant cognitive complaints; differentiate insomnia-related cognitive impairment from neurodegenerative process Document attention, memory, processing speed deficits; correlate with sleep quality None - - EXT -

3. TREATMENT

3A. Non-Pharmacologic Treatment (FIRST LINE — All Patients)

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
CBT-I (Cognitive Behavioral Therapy for Insomnia) - First-line treatment for chronic insomnia; superior to pharmacotherapy for sustained benefit; effective in insomnia comorbid with neurological conditions N/A :: - :: weekly x 6-8 sessions :: Individual or group format; 6-8 weekly sessions with trained therapist; includes cognitive restructuring, stimulus control, sleep restriction, relaxation training; digital CBT-I (e.g., Somryst/Pear) if in-person unavailable Active untreated psychosis; severe cognitive impairment limiting engagement ISI score; sleep diary; treatment adherence - ROUTINE ROUTINE -
Sleep hygiene education - Foundation for all insomnia management; address modifiable behavioral factors N/A :: - :: ongoing :: Consistent sleep-wake schedule 7 days/week; bedroom dark, cool (65-68F), quiet; remove screens from bedroom; no clock-watching; avoid caffeine after noon; avoid alcohol within 4 hours of bedtime; no naps >20 minutes None Adherence; sleep diary ROUTINE ROUTINE ROUTINE -
Stimulus control therapy - Break conditioned association between bed/bedroom and wakefulness; re-establish bed as sleep cue N/A :: - :: nightly :: Go to bed only when sleepy; if unable to sleep within 20 minutes, leave bedroom and return only when sleepy; use bed only for sleep and intimacy; fixed wake time regardless of sleep obtained May be challenging in hospitalized patients or those with mobility limitations Sleep diary; time to sleep onset - ROUTINE ROUTINE -
Sleep restriction therapy - Increase sleep drive by consolidating sleep; improve sleep efficiency N/A :: - :: weekly adjustment :: Restrict time in bed to match current total sleep time (minimum 5 hours); increase by 15-30 minutes weekly when sleep efficiency >85%; decrease by 15 minutes if efficiency <80% Bipolar disorder (risk of mania); epilepsy (sleep deprivation lowers seizure threshold); use with caution in these populations Sleep efficiency; daytime function; seizure frequency in epilepsy patients - - ROUTINE -

3B. First-Line Pharmacotherapy

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Melatonin PO Sleep onset insomnia; preferred in elderly and dementia; circadian rhythm support; minimal side effects and drug interactions 1 mg qHS; 3 mg qHS; 5 mg qHS :: PO :: qHS :: Start 1-3 mg 30-60 minutes before desired bedtime; preferred in elderly and dementia patients due to favorable safety profile; may take 2-4 weeks for full effect; extended-release for sleep maintenance Autoimmune conditions (theoretical); severe hepatic impairment Daytime sedation; headache; vivid dreams - ROUTINE ROUTINE -
Suvorexant (Belsomra) PO Insomnia with difficulty falling asleep and/or staying asleep; preferred in dementia-related insomnia; dual orexin receptor antagonist (DORA) 10 mg qHS; 20 mg qHS :: PO :: qHS :: Start 10 mg within 30 minutes of bedtime; increase to 20 mg if tolerated and needed; effective for sleep onset and maintenance; take only if >=7 hours before planned awakening Narcolepsy; concurrent strong CYP3A4 inhibitors (ketoconazole, itraconazole, clarithromycin); severe hepatic impairment Daytime somnolence; sleep paralysis; hypnagogic hallucinations; suicidal ideation (rare) - ROUTINE ROUTINE -
Lemborexant (Dayvigo) PO Insomnia with difficulty falling asleep and/or staying asleep; dual orexin receptor antagonist; may be better tolerated than suvorexant 5 mg qHS; 10 mg qHS :: PO :: qHS :: Start 5 mg within 30 minutes of bedtime; increase to 10 mg if needed; take only if >=7 hours before planned awakening; dose adjustment with moderate CYP3A4 inhibitors (max 5 mg) Narcolepsy; concurrent strong CYP3A4 inhibitors; severe hepatic impairment Daytime somnolence; sleep paralysis; headache; nightmares - ROUTINE ROUTINE -
Trazodone PO Insomnia with comorbid depression or anxiety; commonly used off-label for insomnia; good for sleep maintenance 25 mg qHS; 50 mg qHS; 100 mg qHS :: PO :: qHS :: Start 25-50 mg at bedtime; titrate by 25 mg every 1-2 weeks; max 100 mg for insomnia indication; serotonin antagonist/reuptake inhibitor Concurrent MAOIs; QT prolongation; severe hepatic impairment Orthostatic hypotension (especially elderly); priapism (rare); next-day sedation; QTc if cardiac risk - ROUTINE ROUTINE -
Ramelteon (Rozerem) PO Sleep onset insomnia; melatonin receptor agonist (MT1/MT2); no abuse potential; safe in elderly; no DEA scheduling 8 mg qHS :: PO :: qHS :: 8 mg within 30 minutes of bedtime; do not take with or immediately after high-fat meal; no dose titration needed; onset within 30 minutes Severe hepatic impairment; concurrent fluvoxamine (strong CYP1A2 inhibitor); history of angioedema to ramelteon Somnolence; dizziness; prolactin levels (with chronic use); reproductive hormone effects - ROUTINE ROUTINE -

3C. Second-Line / Neurological-Specific Pharmacotherapy

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Gabapentin PO Insomnia comorbid with neuropathic pain or restless legs syndrome; dual benefit for sleep and pain/RLS; enhances slow-wave sleep 100 mg qHS; 300 mg qHS; 600 mg qHS :: PO :: qHS :: Start 100-300 mg at bedtime; titrate by 100-300 mg every 3-7 days; max 600 mg qHS for insomnia (higher doses for pain/RLS); renal dose adjustment required Hypersensitivity; severe renal impairment (adjust dose); respiratory depression risk with opioids Sedation; dizziness; peripheral edema; ataxia; renal function; suicidal ideation - ROUTINE ROUTINE -
Amitriptyline PO Insomnia comorbid with chronic headache, neuropathic pain, or fibromyalgia; tricyclic antidepressant with strong sedating properties 10 mg qHS; 25 mg qHS; 50 mg qHS :: PO :: qHS :: Start 10 mg at bedtime; increase by 10-25 mg every 1-2 weeks; max 50 mg for insomnia; dual benefit for headache prophylaxis and neuropathic pain Concurrent MAOIs; recent MI; cardiac conduction disease; narrow-angle glaucoma; urinary retention; AVOID in elderly/dementia (anticholinergic burden, Beers criteria) ECG if cardiac risk or dose >25 mg; anticholinergic effects (dry mouth, constipation, urinary retention); orthostatic hypotension; weight gain; cognitive effects in elderly - ROUTINE ROUTINE -
Mirtazapine PO Insomnia comorbid with poor appetite, weight loss, or depression; most sedating at lower doses (7.5-15 mg) due to predominant antihistaminic effect 7.5 mg qHS; 15 mg qHS :: PO :: qHS :: Start 7.5 mg at bedtime; most sedating at 7.5-15 mg; higher doses (30-45 mg) are less sedating due to increased noradrenergic activity; weight gain is common Concurrent MAOIs; hepatic impairment (reduce dose); renal impairment (reduce dose) Weight; metabolic panel (lipids, glucose); appetite; agranulocytosis (rare; monitor WBC if fever/infection); sedation - ROUTINE ROUTINE -
Doxepin (Silenor) PO Sleep maintenance insomnia; FDA-approved at low doses (3-6 mg) for insomnia; selective histamine H1 antagonist at low dose 3 mg qHS; 6 mg qHS :: PO :: qHS :: Start 3 mg within 30 minutes of bedtime; increase to 6 mg if needed; do not take within 3 hours of a meal; FDA-approved for insomnia at these low doses only Concurrent MAOIs; narrow-angle glaucoma; urinary retention; severe hepatic impairment; use within 3 hours of meal Daytime sedation; nausea; upper respiratory infection (paradoxically common in trials) - ROUTINE ROUTINE -
Quetiapine PO Insomnia with agitation in dementia or Parkinson's disease; also useful for insomnia with comorbid psychosis or severe anxiety; OFF-LABEL for insomnia 25 mg qHS; 50 mg qHS :: PO :: qHS :: Start 12.5-25 mg at bedtime; max 50 mg for insomnia; lowest effective dose; monitor metabolic effects; black box warning for mortality in elderly with dementia-related psychosis Concurrent QT-prolonging drugs; severe hepatic impairment; Lewy body dementia (may worsen motor symptoms; use with extreme caution) Metabolic panel (fasting glucose, lipids, weight) at baseline and q3 months; blood pressure; EPS; tardive dyskinesia; QTc; falls risk - ROUTINE ROUTINE -

3D. Medications to AVOID or Use with Extreme Caution in Neurological Patients

Treatment Route Indication Dosing Contraindications Monitoring ED HOSP OPD ICU
Benzodiazepines (e.g., temazepam, lorazepam, clonazepam) PO AVOID in elderly, dementia, TBI, fall-risk patients; increased risk of falls, cognitive impairment, delirium, dependence, and respiratory depression AVOID :: PO :: - :: Not recommended as first- or second-line for insomnia in neurological patients; if already prescribed, taper gradually over weeks to months to avoid withdrawal seizures Elderly (Beers criteria); dementia; TBI; myasthenia gravis; untreated OSA; history of substance abuse; respiratory insufficiency Cognitive function; falls; respiratory status; dependence; taper if discontinuing - - - -
Zolpidem (Ambien) PO AVOID in dementia, parasomnia-prone patients, and elderly; risk of complex sleep behaviors (sleepwalking, sleep-driving, sleep-eating) AVOID :: PO :: - :: Not recommended in neurological patients due to risk of complex sleep behaviors, falls, and cognitive impairment; if used, lowest dose only (5 mg women, 5-10 mg men) Dementia; history of parasomnias; elderly (Beers criteria); severe hepatic impairment; concurrent CNS depressants Complex sleep behaviors; next-day impairment; falls; cognitive function - - - -
Diphenhydramine (Benadryl) / Hydroxyzine PO AVOID in elderly; high anticholinergic burden; impairs cognition; paradoxical agitation in dementia; tolerance develops rapidly AVOID :: PO :: - :: Not recommended for insomnia treatment in neurological patients; anticholinergic effects worsen cognition in dementia, cause urinary retention, and increase delirium risk Elderly (Beers criteria); dementia; narrow-angle glaucoma; BPH/urinary retention; concurrent anticholinergic medications Cognitive function; anticholinergic burden; falls; delirium - - - -

4. OTHER RECOMMENDATIONS

4A. Referrals & Consults

Recommendation ED HOSP OPD ICU
Sleep medicine specialist for formal insomnia assessment, PSG if comorbid sleep disorder suspected, and CBT-I program coordination - ROUTINE ROUTINE -
Psychology or psychiatry referral for CBT-I delivery; behavioral sleep medicine specialist preferred; digital CBT-I (Somryst/Pear Therapeutics) as alternative when in-person not available - ROUTINE ROUTINE -
Neurology follow-up for underlying neurological condition management (TBI, dementia, MS, Parkinson's, epilepsy, stroke) as insomnia treatment is more effective when comorbid conditions are optimized - ROUTINE ROUTINE -
Psychiatry referral if significant comorbid depression, anxiety, or PTSD contributing to insomnia; concurrent treatment improves outcomes for both conditions - ROUTINE ROUTINE -
Pain management referral if chronic pain is primary driver of sleep disruption; multimodal pain management improves sleep outcomes - ROUTINE ROUTINE -
Physical/occupational therapy for TBI or stroke patients with insomnia to address activity level, daytime structure, and functional recovery - ROUTINE ROUTINE -

4B. Patient/Family Instructions

Recommendation ED HOSP OPD ICU
Insomnia is a treatable condition; behavioral interventions (CBT-I) are more effective than medications long-term and should be pursued as first-line therapy ROUTINE ROUTINE ROUTINE -
Maintain a consistent sleep-wake schedule 7 days per week including weekends; irregular schedules worsen insomnia by disrupting circadian rhythm - ROUTINE ROUTINE -
Keep a daily sleep diary recording bedtime, estimated sleep onset time, number and duration of nighttime awakenings, final wake time, and subjective sleep quality; bring to all appointments - ROUTINE ROUTINE -
Take sleep medications at the time prescribed and allow adequate time for sleep (at least 7 hours for most medications) to avoid next-day impairment - ROUTINE ROUTINE -
Do not increase medication doses without physician guidance; do not combine multiple sleep medications or add alcohol to aid sleep ROUTINE ROUTINE ROUTINE -
Seek urgent care if insomnia is accompanied by hallucinations, severe confusion, new neurological symptoms (weakness, numbness, speech difficulty), or suicidal thoughts ROUTINE ROUTINE ROUTINE -
Avoid screen use (phone, tablet, computer, TV) for at least 30-60 minutes before bedtime as blue light suppresses melatonin and stimulating content increases arousal - ROUTINE ROUTINE -
If you cannot fall asleep within 20 minutes, get out of bed and do a quiet, non-stimulating activity in dim light until you feel sleepy, then return to bed (stimulus control) - ROUTINE ROUTINE -

4C. Lifestyle & Prevention

Recommendation ED HOSP OPD ICU
Regular moderate exercise (30 minutes daily, 5 days/week) improves sleep quality; avoid vigorous exercise within 4 hours of bedtime as it may increase arousal - - ROUTINE -
Morning bright light exposure (30 minutes within 1 hour of waking) helps entrain circadian rhythm and improve sleep onset; especially important in dementia and TBI patients - ROUTINE ROUTINE -
Caffeine cutoff by noon; caffeine half-life is 5-7 hours and even afternoon consumption significantly impairs sleep onset and reduces total sleep time - ROUTINE ROUTINE -
Avoid alcohol as a sleep aid; although it promotes initial sleep onset, alcohol fragments sleep architecture, reduces REM sleep, and worsens insomnia in the second half of the night ROUTINE ROUTINE ROUTINE -
Maintain cool bedroom temperature (65-68 degrees F); core body temperature drop facilitates sleep onset - ROUTINE ROUTINE -
Stress management techniques including progressive muscle relaxation, diaphragmatic breathing, and mindfulness meditation can reduce physiological hyperarousal that perpetuates insomnia - ROUTINE ROUTINE -
Weight management as obesity is associated with OSA, which commonly coexists with and exacerbates insomnia - - ROUTINE -
Limit daytime naps to 20 minutes maximum before 3:00 PM; longer or later naps reduce homeostatic sleep drive and worsen nighttime insomnia - ROUTINE ROUTINE -

5. DIFFERENTIAL DIAGNOSIS

Alternative Diagnosis Key Distinguishing Features Tests to Differentiate
Obstructive sleep apnea (OSA) Snoring, witnessed apneas, obesity, morning headaches; may coexist with insomnia (COMISA); EDS more prominent than in pure insomnia PSG with respiratory scoring; AHI >5 events/hour; STOP-BANG questionnaire
Restless legs syndrome (RLS) / periodic limb movement disorder (PLMD) Urge to move legs worse at rest and evening; sensory discomfort; PLMD causes arousals during sleep; low ferritin common Clinical history (IRLSSG criteria); serum ferritin; PSG showing PLMS >15/hour
Delayed sleep-wake phase disorder (DSWPD) Cannot fall asleep until very late (2-6 AM); normal sleep duration once asleep; difficulty waking for early obligations; common in young adults Actigraphy; sleep diary showing consistent late sleep onset and late wake time; DLMO testing
Advanced sleep-wake phase disorder (ASWPD) Sleepy in early evening; wakes very early (3-5 AM); common in elderly; total sleep time normal Actigraphy; sleep diary showing consistently early sleep onset and early wake time
REM sleep behavior disorder (RBD) Dream enactment behavior; vocalizations during sleep; may cause sleep disruption; strong association with synucleinopathies (Parkinson's, DLB, MSA) PSG with REM without atonia; video documentation; screen for neurodegenerative disease
Medication-induced insomnia Temporal relationship to medication initiation; common offenders: SSRIs, stimulants, beta-blockers, corticosteroids, theophylline, decongestants, levodopa Medication review; temporal correlation; trial of dose adjustment or timing change
Depression-related insomnia Depressed mood, anhedonia, psychomotor changes; early morning awakening classic; terminal insomnia pattern; insomnia may be presenting symptom PHQ-9; psychiatric evaluation; insomnia often improves with depression treatment
Anxiety-related insomnia Rumination, worry, hyperarousal at bedtime; sleep onset insomnia predominant; somatic symptoms of anxiety GAD-7; psychiatric evaluation; cognitive hyperarousal measures
PTSD-related insomnia Nightmares, hypervigilance, avoidance behaviors; insomnia is core PTSD symptom; often treatment-resistant PCL-5; trauma history; PSG may show increased REM density and arousals
Pain-related sleep disruption Chronic pain conditions (neuropathy, headache, fibromyalgia, arthritis) causing frequent arousals; pain worse at night; position-dependent Pain assessment scales; correlate sleep diary with pain diary; treat underlying pain
Nocturnal seizures Stereotyped nocturnal events; sleep fragmentation; may not be recognized as seizures; consider in patients with epilepsy and new insomnia EEG (awake and sleep); video-EEG monitoring; PSG with expanded EEG montage
Insufficient sleep syndrome Chronic voluntary sleep restriction due to work, social, or electronic media; resolves with adequate sleep opportunity Sleep diary and actigraphy showing chronic short sleep time; improvement with sleep extension

6. MONITORING PARAMETERS

Parameter Frequency Target/Threshold Action if Abnormal ED HOSP OPD ICU
Insomnia Severity Index (ISI) Baseline; every 4-6 weeks during active treatment; q3 months once stable ISI <8 (remission); reduction >=8 points clinically significant If ISI >=15 despite 6 weeks of treatment: reassess diagnosis, adherence to CBT-I, medication adjustment - ROUTINE ROUTINE -
Sleep diary review Every visit during active treatment Sleep efficiency >85%; sleep onset latency <30 min; WASO <30 min Adjust sleep restriction window; reinforce stimulus control; consider medication change - ROUTINE ROUTINE -
Medication side effects Each visit; focus on specific medication risks No significant adverse effects Dose reduction, medication switch, or discontinuation - ROUTINE ROUTINE -
Cognitive function (in elderly/dementia patients) Baseline; every 6 months Stable or improved cognitive performance (MMSE, MoCA) Discontinue anticholinergic or sedating medications; reassess sleep medication choice - ROUTINE ROUTINE -
Falls risk assessment (elderly patients) Each visit if age >65 or neurological condition No falls; Timed Up and Go <12 seconds Reduce sedating medications; physical therapy referral; environmental safety evaluation - ROUTINE ROUTINE -
Quetiapine monitoring (if prescribed) Baseline; q3 months: fasting glucose, lipid panel, weight Normal metabolic parameters; no EPS or tardive dyskinesia Lowest effective dose; consider alternative if metabolic changes; AIMS exam annually - ROUTINE ROUTINE -
Trazodone monitoring (if prescribed) Each visit; orthostatic BP at initiation No orthostatic hypotension; no priapism Dose reduction; add fluids/salt; discontinue if priapism occurs (urological emergency) - ROUTINE ROUTINE -
Amitriptyline monitoring (if prescribed) Baseline ECG if cardiac risk; each visit QTc <470 ms; no anticholinergic toxicity Reduce dose; discontinue if QTc prolonged; switch to non-anticholinergic agent - ROUTINE ROUTINE -
Depression/anxiety screening (PHQ-9, GAD-7) Baseline; q3-6 months PHQ-9 <5; GAD-7 <5 Psychiatric referral; medication adjustment; intensify behavioral interventions - ROUTINE ROUTINE -
Daytime function assessment Each visit Improved daytime alertness, concentration, and function Reassess treatment plan; evaluate for comorbid sleep disorders; consider PSG - ROUTINE ROUTINE -

7. DISPOSITION CRITERIA

Disposition Criteria
Outpatient management Vast majority of insomnia patients; uncomplicated insomnia for CBT-I and/or pharmacotherapy; insomnia comorbid with stable neurological conditions
Admit for PSG If comorbid OSA, PLMD, RBD, or nocturnal seizures suspected and outpatient PSG not feasible; schedule PSG night
Admit to floor Severe sleep deprivation with psychosis or delirium; TBI with severe insomnia and neurobehavioral dysregulation; acute neurological condition (stroke, MS relapse, status epilepticus) with significant sleep disruption requiring inpatient management
Transfer to higher level Not typically applicable for insomnia; consider if severe insomnia-related delirium with agitation requires closer monitoring or if underlying neurological condition warrants ICU care
Sleep medicine referral All patients with insomnia refractory to initial treatment (>=6 weeks CBT-I without improvement); suspected comorbid sleep disorder; need for PSG
Neurology referral Insomnia with new neurological symptoms; suspected neurodegenerative disease; TBI-related insomnia; seizure-related sleep disruption
Psychiatry referral Insomnia with significant comorbid depression, anxiety, PTSD, or substance use; suicidal ideation; medication management complexity
Follow-up frequency Every 2-4 weeks during initial CBT-I or medication titration; every 3 months once stable; annually if in long-term remission

8. EVIDENCE & REFERENCES

Recommendation Evidence Level Source
CBT-I as first-line treatment for chronic insomnia in adults Guideline, Strong recommendation Qaseem et al. Ann Intern Med 2016
European guideline on insomnia diagnosis and treatment; strong recommendation for CBT-I; conditional for pharmacotherapy Guideline, GRADE methodology Riemann et al. J Sleep Res 2017
Suvorexant (DORA) improves sleep in patients with Alzheimer's disease insomnia without worsening cognition Class I, Level A Herring et al. Ann Neurol 2020
CBT-I produces sustained improvements in sleep onset latency and wake after sleep onset; meta-analysis of 20 RCTs Class I, Level A (meta-analysis) Trauer et al. Ann Intern Med 2015
AASM clinical practice guideline for pharmacologic treatment of chronic insomnia; recommendations for suvorexant, doxepin, ramelteon, and others Guideline, systematic review Sateia et al. J Clin Sleep Med 2017
CBT-I effective for insomnia following TBI; significant improvements in ISI and sleep diary parameters Class II, Level B Ouellet et al. J Head Trauma Rehabil 2015
Lemborexant efficacy and safety for insomnia disorder (SUNRISE 1 and 2 trials) Class I, Level A Rosenberg et al. JAMA Netw Open 2019
Low-dose doxepin (3-6 mg) FDA-approved for sleep maintenance insomnia; selective H1 antagonism at low doses Class I, Level A Krystal et al. Sleep 2011
Gabapentin improves sleep in patients with restless legs syndrome and comorbid insomnia Class I, Level A Winkelman et al. Sleep Med 2007
Ramelteon efficacy for sleep onset insomnia; melatonin receptor agonist with no abuse potential Class I, Level A Roth et al. Sleep Med 2006
Insomnia as risk factor for cognitive decline and dementia in older adults Class II, Level B Shi et al. Sleep Med Rev 2018
AAN practice parameter on insomnia in neurological conditions; behavioral interventions recommended across neurological populations Practice parameter Silber et al. Neurology 2004

NOTES

  • Insomnia is the most common sleep disorder, affecting approximately 10-15% of adults with chronic insomnia and 30-35% with acute insomnia symptoms
  • CBT-I is recommended as first-line treatment by the ACP, AASM, and European Sleep Research Society; it is effective for insomnia comorbid with neurological conditions including TBI, dementia, Parkinson's disease, MS, and chronic pain
  • The "3P model" of insomnia (predisposing, precipitating, perpetuating factors) guides treatment: address perpetuating factors (maladaptive sleep behaviors, conditioned arousal) through CBT-I even when predisposing or precipitating factors are neurological
  • Dual orexin receptor antagonists (DORAs: suvorexant, lemborexant) are emerging as preferred pharmacotherapy, especially in elderly and dementia patients, due to favorable safety profile compared to benzodiazepine receptor agonists
  • Sleep restriction therapy should be used with caution in epilepsy patients as acute sleep deprivation can lower seizure threshold; minimum time in bed should be 5-6 hours and titration should be conservative
  • Trazodone is the most commonly prescribed medication for insomnia despite limited RCT evidence for this indication; its use is largely based on clinical experience and favorable side effect profile
  • Avoid benzodiazepines and "Z-drugs" (zolpidem, zaleplon, eszopiclone) in elderly and neurological patients due to increased risk of falls, cognitive impairment, delirium, complex sleep behaviors, and dependence
  • Anticholinergic medications (diphenhydramine, hydroxyzine, older antihistamines) are Beers criteria inappropriate in elderly patients; they worsen cognition, cause urinary retention, and increase delirium risk
  • Insomnia in Parkinson's disease is multifactorial: dopaminergic medication effects, RBD, nocturia, restless legs, pain, depression, and neurodegeneration of sleep-regulating circuits
  • Insomnia in TBI patients is extremely common (30-70%) and often persists long after injury; CBT-I is effective but may need modification for cognitive deficits
  • Comorbid insomnia and obstructive sleep apnea (COMISA) affects approximately 30-50% of patients with either disorder; treating both conditions simultaneously improves outcomes
  • Low melatonin production in elderly and dementia patients provides rationale for exogenous melatonin supplementation; extended-release formulations may better address sleep maintenance
  • Always screen for depression (PHQ-9), anxiety (GAD-7), and substance use when evaluating insomnia; bidirectional relationships between insomnia and psychiatric conditions are well-established
  • In hospitalized neurological patients, optimize the sleep environment: minimize nighttime vitals checks when clinically safe, reduce ambient noise and light, cluster nursing care, maintain day-night lighting cues

CHANGE LOG

v1.0 (February 7, 2026) - Initial template creation - ICSD-3-TR / DSM-5-TR diagnostic criteria for insomnia disorder - Comprehensive non-pharmacologic treatment: CBT-I, sleep hygiene, stimulus control, sleep restriction as first-line - First-line pharmacotherapy: melatonin, suvorexant, lemborexant, trazodone, ramelteon - Second-line neurological-specific agents: gabapentin, amitriptyline, mirtazapine, doxepin, quetiapine - Medications to avoid/caution section: benzodiazepines, zolpidem, diphenhydramine in neurological patients - Neurological comorbidity-focused scope: TBI, dementia, MS, Parkinson's, epilepsy, stroke, chronic pain - PubMed citations for all major evidence sources - ISI, PSQI, ESS validated instruments included - Differential diagnosis including COMISA, RBD, circadian rhythm disorders, and neurological mimics