Grades are shown as the source states them. The European guideline grades recommendations A (very strong), B (strong), C (weak) and D (very weak). The AASM and the systematic review use GRADE (strong or conditional, with the certainty of evidence).
Key recommendations
Chronic insomnia: difficulty falling asleep, staying asleep or waking too early, with daytime impairment, at least three nights a week for at least 3 months, and not better explained by another sleep disorder. DSM-5, ICSD-3 and ICD-11 (code 7A00) now broadly agree on these criteria.
Diagnosis of insomnia; Tables 2 and 3European Sleep Research Society (ESRS) and European Insomnia Network 2023
Treat insomnia disorder actively whenever it is present. With other conditions, use clinical judgement to decide whether to treat the insomnia first, the other condition first, or both together.
ATable 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Cognitive-behavioural therapy for insomnia (CBT-I) is the first-line treatment for chronic insomnia in adults of any age, including people with other conditions, delivered in person or digitally.
ASummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Offer a medicine only if CBT-I has not worked well enough.
ASummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Antihistamines, antipsychotics, fast-release melatonin, ramelteon and herbal remedies are not recommended for insomnia.
ASummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
In older adults, consider stopping longer-term use of Z-drugs, mainly because of the high risk of falls and fractures.
Strong; low certaintyRecommendationSystematic review for recommendations to reduce potentially inappropriate prescribing in older adults 2022
Diagnosis
Diagnose from a clinical interview covering sleep and medical history, supported by sleep questionnaires such as the Insomnia Severity Index and a sleep diary kept for 7–14 days, with physical examination and further tests where indicated.
ASummary; Sleep diaries and questionnairesEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Ask about past and current physical, neurological and mental disorders; medicines, alcohol, caffeine, nicotine and other drugs; work and daily rhythm; and daytime sleep. Ask a bed partner or caregiver about snoring, pauses in breathing, leg movements, night-time restlessness and unusual behaviours.
ATable 4European Sleep Research Society (ESRS) and European Insomnia Network 2023
Insomnia is diagnosed alongside other conditions rather than dismissed as "secondary": the older division into primary and secondary insomnia was dropped because it was not evidence-based. Explore mental disorders actively, as they may not be mentioned.
Diagnosis of insomnia: insomnia complaint; comorbidityEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Investigations
Actigraphy is not recommended for routine assessment, but helps with differential diagnosis — for example when an irregular sleep–wake pattern, a circadian rhythm disorder or periodic leg movements are suspected.
C for routine use; A for differential diagnosisSummary; Table 4European Sleep Research Society (ESRS) and European Insomnia Network 2023
Use polysomnography when another sleep disorder (such as periodic limb movement disorder or sleep-related breathing disorder) is suspected, and for insomnia that does not respond to treatment.
ASummary; Table 4European Sleep Research Society (ESRS) and European Insomnia Network 2023
Where indicated, blood tests can include a blood count, thyroid, liver and kidney function, C-reactive protein, haemoglobin, ferritin and vitamin B12.
Table 4European Sleep Research Society (ESRS) and European Insomnia Network 2023
Treatment
CBT-I combines psychoeducation (including sleep hygiene), relaxation, sleep restriction, stimulus control and cognitive techniques. Sleep restriction and stimulus control are its most active ingredients.
BCognitive-behavioural therapy for insomnia; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Sleep hygiene advice on its own is not an effective treatment for chronic insomnia, partly because most people already know it.
Psychoeducation/sleep hygieneEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Benzodiazepines and benzodiazepine receptor agonists (Z-drugs) can be used short term, for up to 4 weeks. Longer use is off-label and only for some people, preferably intermittently, after discussing the benefits and harms.
A for short-term use; B for longer-term useSummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Low doses of sedating antidepressants can be considered short term (off-label), taking care over contraindications.
BTable 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Orexin receptor antagonists such as daridorexant can be used for up to 3 months, and longer in some cases after discussing benefits and harms.
ASummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Prolonged-release melatonin can be used for up to 3 months in people aged 55 and over. Fast-release melatonin generally does not work for insomnia unless circadian factors are involved.
B for prolonged-release; A against fast-releaseSummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
Light therapy and exercise may be useful additions to CBT-I.
BSummary; Table 16European Sleep Research Society (ESRS) and European Insomnia Network 2023
If medicine is used, combining it with CBT-I is suggested over medicine alone.
Conditional; low certaintyRecommendation 1American Academy of Sleep Medicine (AASM) 2026
Starting CBT-I and medicine together is not suggested over CBT-I alone, though people who value more sleep early in treatment may reasonably choose it.
Conditional; low certaintyRecommendation 2 and remarkAmerican Academy of Sleep Medicine (AASM) 2026
Important geriatric considerations
Harms of benzodiazepines and Z-drugs include tolerance and dependence, night-time confusion and falls, memory impairment, next-day hangover with impaired driving (especially with long half-life drugs), and rebound insomnia on stopping.
Pharmacological interventions: benzodiazepines and benzodiazepine receptor agonistsEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
In people aged 65 and over, short trials found Z-drugs effective with acceptable safety, but longer-term observational studies showed more falls, fractures (including hip fractures) and traumatic brain injury.
Abstract; Safety and adverse effectsSystematic review for recommendations to reduce potentially inappropriate prescribing in older adults 2022
Sleep restriction delivered by nurses was not associated with serious adverse events, including falls, compared with sleep hygiene advice.
Cognitive-behavioural therapy for insomnia: sleep restriction therapyEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Insomnia is common in stroke and Parkinson's disease, and is an independent risk factor for stroke and dementia.
Diagnosis of insomnia: comorbidityEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Sleep restriction and stimulus control can be demanding and may increase daytime sleepiness and fatigue at first; discuss safety and the person's readiness before starting.
Cognitive-behavioural therapy for insomnia: componentsEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
For people who depend on sleeping tablets and want to stop, help them taper off; CBT-I can support withdrawal.
Figure 1; Final remarksEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Drug doses
Not covered in this summary — see the original guideline.
When to refer
Refer for sleep studies (polysomnography) when another sleep disorder is suspected or insomnia does not respond to treatment.
ASummaryEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
Red flags
Loud snoring or pauses in breathing, leg jerks, or unusual behaviours at night reported by a partner or caregiver point to another sleep disorder that needs assessment.
Table 4European Sleep Research Society (ESRS) and European Insomnia Network 2023
Recent updates
The 2023 European update recommends orexin receptor antagonists such as daridorexant and accepts digital CBT-I as first-line treatment. ICD-11 replaces the old organic versus non-organic split with a single category of chronic insomnia.
Summary; IntroductionEuropean Sleep Research Society (ESRS) and European Insomnia Network 2023
The 2026 AASM guideline is the first to address starting CBT-I and medicine together: it favours combination over medicine alone, but not over CBT-I alone.