A 34-year-old woman with a history of migraine headaches comes to the office due to insomnia. She has difficulties with sleep initiation/maintenance that started 5 years ago when she became the caretaker for her mother, who had Alzheimer dementia. She slept poorly as she had to be alert in case her mother called for her during the night. Although her mother passed away 3 years ago, the patient still has insomnia.
The patient takes 1 hour to fall asleep. She wakes up twice in the middle of the night and may take up to 45 minutes to fall back asleep. When she can't sleep, she stays in bed thinking about her career, lack of social life, and "ticking biological clock." She is exhausted the next day. The patient has no snoring or awakenings with gasping. She does not feel depressed. There is no history of tobacco, alcohol, or illegal drug use.
Vital signs are within normal limits. The patient is thin and in no acute distress. Physical examination is unremarkable.
Which of the following is the most appropriate treatment for this patient's insomnia?

Question

A 34-year-old woman with a history of migraine headaches comes to the office due to insomnia.  She has difficulties with sleep initiation/maintenance that started 5 years ago when she became the caretaker for her mother, who had Alzheimer dementia.  She slept poorly as she had to be alert in case her mother called for her during the night.  Although her mother passed away 3 years ago, the patient still has insomnia.
The patient takes >1 hour to fall asleep.  She wakes up twice in the middle of the night and may take up to 45 minutes to fall back asleep.  When she can't sleep, she stays in bed thinking about her career, lack of social life, and "ticking biological clock."  She is exhausted the next day.  The patient has no snoring or awakenings with gasping.  She does not feel depressed.  There is no history of tobacco, alcohol, or illegal drug use.
Vital signs are within normal limits.  The patient is thin and in no acute distress.  Physical examination is unremarkable.
Which of the following is the most appropriate treatment for this patient's insomnia?

Quizplus · Accepted Answer

11ec193a_98ad_b07b_853d_ed24feada6b3_MD0002_00 Nonpharmacologic management, rather than hypnotic medications, is the recommended initial treatment for chronic insomnia. Cognitive-behavioral therapy (CBT) for insomnia is the treatment of choice and should be recommended to this patient. CBT for insomnia combines several approaches, including cognitive therapy to address dysfunctional thoughts about sleep, and behavioral measures such as sleep hygiene, sleep restriction, stimulus control, and relaxation techniques. The benefits of CBT persist beyond the active treatment period. Hypnotic medications should be reserved for patients who do not improve with CBT alone. Common adverse effects associated with benzodiazepines and nonbenzodiazepine hypnotics include residual daytime sedation, drowsiness, dizziness, lightheadedness, cognitive impairment, motor incoordination, and dependence. Long-term treatment of insomnia with medication alone is unlikely to be beneficial. (Choice B) Melatonin is not recommended as an initial treatment for insomnia unless the sleep disturbance is due to delayed sleep-wake phase syndrome (a circadian rhythm disorder with bedtimes and wake times significantly later than conventional or desired times). Patients with chronic insomnia have difficulty falling asleep regardless of bedtime; in delayed sleep-wake phase syndrome, patients fall asleep readily when allowed to sleep at desired times. (Choice C) Benzodiazepines (eg, temazepam) should be avoided in treating chronic insomnia as tolerance typically develops to their hypnotic effects and they are associated with risks of abuse and dependence. (Choice D) Although low doses of the sedating antidepressant trazodone have been used to treat insomnia, this medication is associated with significant side effects and is not recommended as initial treatment. (Choice E) The nonbenzodiazepine zolpidem is effective for the short-term treatment of insomnia but is also associated with adverse effects, including somnolence and cognitive impairment. Educational objective: Cognitive-behavioral therapy (CBT) is the first-line treatment for chronic insomnia. Patients with continued severe insomnia can be treated with a combination of CBT and short-term pharmacotherapy. __________ References: Advances in the management of chronic insomnia. (http://www.ncbi.nlm.nih.gov/pubmed/27383400) Cognitive and behavioral therapies in the treatment of insomnia: a meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/28392168)

A 34-Year-Old Woman with a History of Migraine Headaches Comes