Millions of Americans keep a bottle of something by the bed to help them sleep. But many of the most popular options come with real risks and surprisingly little evidence behind them.
Two orthopedic surgeons and hosts of the "Talking with Docs" channel, Dr. Brad Winn and Dr. Paul Zalza, recently reviewed the most common over-the-counter and prescription sleep aids. Their central message: "None of them are perfect," and fixing the cause of poor sleep usually works better over the long run than trying to make yourself drowsy.
Start With Why You Can't Sleep
Before reaching for a pill, the doctors say the first question is whether something correctable is keeping you awake.
Insomnia is defined as trouble falling asleep, staying asleep, or getting restful sleep despite having the opportunity to sleep, with effects that carry into the next day. But several common problems can look like insomnia, including sleep apnea, restless legs, chronic pain, anxiety or depression, and caffeine or alcohol too close to bedtime.
Practicing good sleep hygiene and addressing these factors, the doctors said, is often enough to improve sleep for most people.
For chronic insomnia, the first-line treatment recommended by major medical groups is cognitive behavioral therapy for insomnia (CBT-I). Zalza described it as "physical therapy for sleeping." It can include limiting the time you spend in bed, going to bed only when you are sleepy, and training your mind to associate the bed with sleep. The doctors noted that they are not sleep specialists, but that the therapy is widely reported to work well.
Over-the-Counter Options: Limited Benefits, Real Downsides
Diphenhydramine (Benadryl and "PM" products). This old antihistamine is the active ingredient in many products labeled "PM," including Tylenol PM and Advil PM. It does cause drowsiness, but the body quickly gets used to it, so people may need more over time.
The bigger concern is safety. The doctors said their greatest worry with almost any sleep aid is the risk of falls, especially in older adults. A person takes a sleep aid, gets up in the night, and ends up with a hip injury or another serious one. Diphenhydramine also has anticholinergic effects, including dry mouth, constipation, difficulty urinating, blurred vision, and next-day grogginess that can make morning driving unsafe.
"In a pinch," the doctors said, it might get you through a night or two, but it is not a long-term solution.
Melatonin. One of the most widely used sleep supplements, melatonin is a hormone that helps regulate the body's internal clock. The doctors said it is most useful when your circadian rhythm is disrupted, such as with jet lag or night-shift work.
For everyday, chronic sleep trouble, its benefit appears modest. Research suggests it may help people fall asleep only slightly faster on average. The doctors also cautioned against escalating the dose. Products range from 1 milligram to 10 milligrams or more, and some people take 20 milligrams, with diminishing returns at higher doses.
Product quality is another concern. Testing of melatonin gummies has found that the amount in the bottle can differ widely from what the label says.
Magnesium. Magnesium is popular for countless uses, but the doctors said the evidence that it helps sleep is weak unless you are actually deficient. If a deficiency is disrupting your sleep, restoring normal levels makes sense. Beyond that, high doses have not been shown to improve sleep, and they can cause loose stools, which could send you to the bathroom in the middle of the night.
Prescription Medications: Effective for Some, but With Trade-Offs
Z-drugs (zolpidem/Ambien, eszopiclone/Lunesta). These have long been widely prescribed, and the evidence that they help is moderate. The doctors said they carry a high risk of falls and next-morning impairment. They can also trigger abnormal behaviors such as sleepwalking and sleep eating. The FDA requires a boxed warning about complex sleep behaviors, which can be dangerous.
Benzodiazepines (such as temazepam and diazepam). These drugs work on the brain's GABA system and are also commonly used for anxiety. The doctors pointed to their potential for dependence, tolerance, and withdrawal symptoms after stopping, as well as a significant increase in fall risk, particularly in older adults.
Trazodone. Trazodone is an antidepressant frequently prescribed for sleep. The doctors said there is not much good evidence supporting that use, even though it is prescribed often. Clinical guidelines from the American Academy of Sleep Medicine recommend against using it for insomnia.
Orexin antagonists (such as lemborexant/Dayvigo). This newer class of drugs, developed after the discovery of the wakefulness-promoting hormone orexin in 1998, works differently. Rather than making you drowsy, they dampen the brain's wake signal.
According to the doctors, this class has the most supporting evidence among prescription options, including for helping people stay asleep and not just fall asleep. Winn and Zalza said lemborexant, in their view, offers a favorable balance of safety and effect, though it is not risk-free. Possible side effects include dizziness and next-day sleepiness, vivid or unusual dreams, and, in some people, episodes of sleep paralysis, where a person feels awake but unable to move.
What to Do Before Taking Anything
The doctors emphasized that the list of medications they covered is not exhaustive, and that other options exist. Their practical advice was consistent:
- Cut back on alcohol and caffeine, especially later in the day.
- Follow good sleep hygiene and wind down before bed.
- Get evaluated for treatable causes such as sleep apnea or restless legs, and consider CBT-I if you have anxiety or depression.
- Be cautious if you take a sleep aid: avoid driving the next morning if you feel groggy, and take precautions against nighttime falls.
Many of these medications appear on the American Geriatrics Society's list of drugs to avoid in adults 65 and older, largely because of fall and confusion risks.
The doctors urged anyone taking other medications, especially older adults, to talk with a pharmacist or health care provider before adding a sleep aid, to avoid dangerous interactions.
"You are in charge of your own health," Zalza said. Sometimes the best sleep aid is finding out what is keeping you awake in the first place.
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