Within the context of the comprehensive treatment of
sleep disorders, which includes medical, neurologic, psychiatric, and social interventions, use of medication is often indicated. Among the three
benzodiazepine hypnotics that are available in the United States for the treatment of
insomnia,
flurazepam is effective for both sleep induction and maintenance, and it retains most of its efficacy over a 4-week period of nightly administration;
temazepam is effective only for sleep maintenance, and
triazolam improves both sleep induction and maintenance with initial but not with continued administration. Rebound phenomena are more frequent and intense with the more rapidly eliminated
drug,
triazolam, and to a lesser degree with
temazepam. Also, with
triazolam, certain behavioral side effects, such as
amnesia and psychotic-like symptoms, have been reported. With
flurazepam, which is a slowly eliminated
benzodiazepine, daytime sedation is more frequent than with the other two drugs. When
insomnia is secondary to major depression,
antidepressant medication should be administered.
Methylphenidate,
amphetamines, or other stimulant medications are used for the symptomatic treatment of the
sleepiness and sleep attacks of
narcolepsy and
hypersomnia. For
cataplexy and the other two auxiliary symptoms of
narcolepsy,
imipramine or other tricyclics are the drugs of choice.
Protriptyline and
medroxyprogesterone have been used in treating mild cases of
obstructive sleep apnea, but their efficacy is limited. Similarly, for the treatment of
central sleep apnea,
medroxyprogesterone and
acetazolamide have shown only limited effects. Medication for patients with
sleepwalking,
night terrors, or nightmares should be prescribed judiciously, and primarily when treatment of an underlying psychiatric condition is desired. The neuropharmacology of sleep should also consider drugs that may cause
sleep disorders. Medications with sleep disturbing effects include various
antihypertensives,
bronchodilators, and the energizing
antidepressants. Withdrawal of REM-suppressant drugs, such as the
barbiturates, may cause nightmares in association with a REM rebound. Occasionally, a
drug or a combination of drugs may produce somnambulistic-like activity in some patients.