Cognitive behavioral therapy for insomnia (CBT-I) remains the gold standard for treating chronic sleep problems, even as new guidelines suggest combining it with medication may help some patients. The American Academy of Sleep Medicine (AASM) released updated recommendations in August 2026 that reshape how doctors approach one of America's most common sleep disorders, affecting roughly 20 to 50 percent of people who visit primary care clinics.

What Changed in the Latest Insomnia Treatment Guidelines?

The AASM's new guidance on combination treatment for chronic insomnia marks a subtle but important shift in clinical practice. The organization now suggests that CBT-I plus medication is preferable to medication alone, yet it still ranks CBT-I by itself above the combination approach. This recommendation is conditional and based on low-certainty evidence, meaning doctors and patients should discuss what works best for their specific situation rather than following a one-size-fits-all protocol.

One notable gap in the evidence: the guidelines found no eligible studies examining dual orexin receptor antagonists or melatonin receptor agonists in combination with CBT-I. This means newer sleep drugs like lemborexant and daridorexant have no combination evidence supporting or opposing their use alongside therapy.

Why Is CBT-I Still Considered the First-Line Treatment?

CBT-I works differently than sleep medications. Rather than chemically inducing drowsiness, it targets the thoughts and behaviors that keep people awake. The therapy helps patients identify and change patterns like racing thoughts at bedtime, excessive time spent in bed trying to force sleep, and anxiety about sleep itself. Research suggests CBT-I may be more effective for long-term insomnia management in the general population than sleep medications alone.

For people with multiple sclerosis, which affects roughly 50 percent of patients with sleep problems, CBT-I has become an increasingly popular option. The therapy addresses the root causes of sleeplessness rather than masking symptoms, which is why medical organizations continue to recommend it as the starting point for chronic insomnia treatment.

How to Build an Effective Insomnia Treatment Plan

• Start with CBT-I: Work with a therapist trained in cognitive behavioral therapy for insomnia to identify and modify sleep-disrupting thoughts and behaviors before considering medication.
• Consider combination therapy if needed: If CBT-I alone doesn't provide adequate relief after a reasonable trial period, adding a prescription sleep medication may be appropriate under medical supervision.
• Rule out underlying medical causes: Before starting any sleep treatment, ensure your doctor has evaluated whether conditions like sleep apnea, thyroid disorders, or other medical issues are driving your insomnia.
• Discuss medication options carefully: If medication is needed, talk with your doctor about the specific type, potential side effects, and how long you'll take it, since some sleep drugs can cause dependence or next-day drowsiness.
• Monitor your response: Whether using therapy, medication, or both, track your sleep patterns and symptoms regularly so your healthcare team can adjust your treatment plan as needed.

What Sleep Medications Are Available, and How Do They Work?

Several classes of prescription sleep aids exist, each with different mechanisms and safety profiles. Benzodiazepines enhance a brain chemical called GABA to slow activity and promote sleep, but they can cause dependence and increase fall risk. Z-drugs work similarly to benzodiazepines but are designed to be shorter-acting. Dual orexin receptor antagonists block signals that promote wakefulness, while melatonin receptor agonists work with the body's natural sleep hormone to regulate the sleep-wake cycle.

Certain antidepressants may also be prescribed for insomnia when it occurs alongside depression or anxiety, though not all are FDA-approved specifically for sleep. The safety of any prescription sleep medicine depends on your individual health conditions, other medications you take, and how your body responds to the drug.

Over-the-counter sleep aids, often containing antihistamines, are generally not recommended for regular treatment of chronic insomnia. While available without a prescription, they carry risks including daytime drowsiness, memory problems, dry mouth, and constipation. For people with MS or other conditions involving fatigue or cognitive symptoms, these side effects can be particularly problematic. Tolerance also develops over time, meaning the medication becomes less effective while side effects persist.

What About Melatonin and Other Supplements?

Melatonin, a natural hormone that signals your body it's time to sleep, is available as a dietary supplement in the United States. Early research suggests it may help some people with MS sleep better. In a 2021 pilot study, people with MS who took melatonin for two weeks experienced significantly longer total sleep time and a trend toward better sleep efficiency. A small randomized study of 27 people with MS also found improvements in fatigue and neuropathic pain after 12 weeks of melatonin compared with placebo.

However, important caveats apply. Melatonin is sold as a dietary supplement, not as an FDA-approved insomnia medicine, which means the amount in a supplement may differ from what the label claims. Information about long-term safety is limited, and melatonin can interact with medications. Always ask your healthcare provider before using melatonin or any supplement, especially if you take other medications.

The bottom line: while new combination approaches offer flexibility, the evidence still supports starting with CBT-I for chronic insomnia. If medication becomes necessary, working closely with your doctor to choose the right drug, monitor side effects, and regularly reassess your treatment plan remains essential for safe and effective sleep management.