If you live with treatment-resistant insomnia, it means first-line therapies were likely ineffective for treating your condition. Finding relief may require exploring new pharmaceutical options and less typical treatments.
It happens to everyone at one point or another — being unable to fall asleep, stay asleep, or get back to sleep if you wake up. When these experiences become a pattern that affects your ability to function, however, you may be diagnosed with insomnia.
Insomnia is a sleep disorder that affects the duration and quality of your sleep at night. It can also cause persistent sleepiness during the day and affect mood and your ability to concentrate.
Lifestyle modifications, behavioral therapies, and medications are all used to treat this condition. When some of the first-line treatments don’t work for you, you may have treatment-resistant insomnia.
There’s no standardized definition for treatment-resistant insomnia. In medical literature, it’s also known as refractory insomnia, residual insomnia, or persistent insomnia.
Despite the lack of a clear, universal definition, “treatment-resistant” is often used to describe insomnia that doesn’t show significant improvement after being treated with two or more first-line therapies.
There are many approaches to treating insomnia, and most experts suggest starting with cognitive behavioral therapy, if available. Then, if necessary, medications.
Living with treatment-resistant insomnia doesn’t mean there is no hope for your symptoms. There are now many different medications available to treat insomnia, and it’s possible you simply haven’t found the right combination for your needs.
Common medications used to treat insomnia include:
- benzodiazepines such as temazepam and triazolam
- benzodiazepine receptor agonists like zolpidem (Ambien), eszopiclone (Lunesta), or zaleplon
- melatonin receptor agonists such as ramelteon
- orexin receptor antagonists like suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq)
These medications work by influencing the neurotransmitter networks in your brain associated with sleep-wake cycles.
In treatment-resistant insomnia, your doctor may consider adding unconventional medications or those used “off-label” to treat insomnia.
Off-label use of medication means a substance hasn’t been evaluated by regulatory bodies for safety or effectiveness for that particular purpose. Doctors sometimes use products off-label when there is an abundance of practical and clinical proof to support the therapy.
Off-label medications occasionally used to treat insomnia include:
- atypical antipsychotics, such as quetiapine
- antidepressants, such as trazodone (not FDA-approved to treat insomnia) or low dose doxepin (FDA-approved to treat insomnia)
Clinical guidelines for chronic insomnia
Chronic insomnia, which lasts 3 or more months, affects approximately 10% to 15% of adults with an insomnia diagnosis.
When insomnia doesn’t respond to treatment, it can become chronic, persisting over an extended period of time. Not all cases of treatment-resistant insomnia are chronic. You can have short-term insomnia that doesn’t respond to therapies, too.
If you do have chronic insomnia, clinical practice guidelines released in 2017 by the American Academy of Sleep Medicine and other
These recommendations include:
- Sleep-onset chronic insomnia: zaleplon, triazolam, and ramelteon
- Sleep-maintenance insomnia: doxepin and suvorexant
- Sleep-onset and sleep-maintenance insomnia combined: eszopiclone, zolpidem, and temazepam
No such guidelines currently exist for short-term treatment-resistant insomnia.
Emerging therapies
Research into new medications and therapies for insomnia is ongoing.
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A clinical trial proposed in 2020 plans to investigate the benefits of electroacupuncture for treatment-resistant insomnia. A telemedicine trial from 2023 found mindfulness-based therapies showed promise for improving treatment-resistant insomnia symptoms like sleep disturbances, depression, and cognitive arousal.
If you’re experiencing treatment-resistant insomnia, a doctor can discuss which current and emerging therapies may improve your symptoms.
There’s no known, singular cause of treatment-resistant insomnia, and treatment resistance in insomnia can be controversial.
Some experts feel the broad range of causes and effective insomnia treatments make this condition difficult to define. Like other conditions with multiple contributing factors, it’s natural that what works for one person might not work for another. This variability makes it challenging to clearly identify what might be treatment resistance.
If your insomnia symptoms don’t improve on a specific medication or therapy, individual factors may play a role, such as your:
- age
- lifestyle
- environment
- general health
Ultimately, insomnia can have a variety of underlying causes that might affect how it responds to treatment.
Sleep disorders
Insomnia itself is a sleep disorder. When it occurs without another explanatory medical condition, it’s called primary insomnia.
You can experience insomnia secondary to other conditions, including other sleep disorders. For example, sleep disorders that can feature insomnia include:
Working with a sleep specialist or doctor can help you manage insomnia and other symptoms of sleep disorders.
Chronic stress
Chronic stress can disrupt multiple processes in the body, including sleep. When you’re fixated on a worry or fear, you might not be able to fall asleep or stay asleep. Learning ways to cope with stress may prevent it from affecting your sleep.
Consider practicing a relaxation routine every night before bed.
Substance use
Different substances affect your brain in unique ways. Some can promote alertness, for example, and others can alter neurotransmitters essential for sleep function.
Discussing substance use with your doctor can clue you into how it’s affecting your sleep.
Adjusting the time of day or frequency you take these substances may help.
Genetics
Certain genetics may increase the likelihood of developing insomnia. You can manage this risk factor by focusing on healthy sleep habits and a lifestyle that reduces insomnia risk.
Mental health conditions
Sleep disturbances are common in certain mental health conditions. The following conditions can feature insomnia as a secondary symptom:
Working with a mental health professional to treat underlying mental health conditions can help improve secondary symptoms of insomnia.
Unhealthy sleep hygiene
It’s possible that your sleep habits are making it challenging to maintain a regular sleep-wake cycle. Being inconsistent with your bedtime, eating heavy meals before sleeping, and spending too much time on screens right before bed can all affect sleep quality.
Practicing sleep hygiene can help.
Sleep hygiene refers to sleep habits that promote optimal sleep, such as:
- going to bed and waking up at the same time every day
- keeping your bedroom dark, quiet, and cool
- avoiding stimulants like caffeine before bed
- limiting alcohol and tobacco consumption
- avoiding electronic screen time before sleeping
- keeping naps short and limited in frequency
Other medical conditions and medications used to treat them
In addition to mental health conditions and sleep disorders, insomnia can be secondary to many other medical conditions. For example, the following can cause sleep disturbances that result in insomnia:
- neurological disorders
- chronic pain conditions
- gastrointestinal disorders
- cardiovascular disorders
Many medications can also cause insomnia, so always discuss this issue with your doctor.
Working closely with a doctor can help you manage chronic medical conditions. This will help decrease their impact on your sleep.
Lifestyle changes to improve insomnia are universal, regardless of whether your insomnia is resistant to treatments or not.
In addition to improving sleep hygiene practices, general lifestyle changes to help symptoms of insomnia include:
- getting regular exercise
- developing stress reduction and management techniques
- engaging in relaxation strategies
- limiting stimulants like caffeine and nicotine, especially late in the day
- prioritizing a balanced diet
- stopping smoking
Another valuable lifestyle change you can make is increasing your support network. Living with insomnia can be overwhelming at times. Surrounding yourself with loved ones and joining support groups can help relieve anxiety and ward off feelings of isolation.
Treatment-resistant insomnia is a topic of debate in the scientific community. While it can represent insomnia that hasn’t responded to several mainstream therapies, some experts feel the variables associated with insomnia naturally make its treatments very individual.
If you’ve tried multiple insomnia treatments and your symptoms aren’t improving, a doctor can discuss alternative pharmaceutical and therapeutic options.
