Insomnia in neurological diseases

Overview

This guideline, published in Neurological Research and Practice in 2021 by German neurological and sleep medicine societies together with patient organizations, addresses insomnia that occurs alongside neurological diseases. Insomnia means difficulty initiating or maintaining sleep, early waking or poor sleep quality despite adequate opportunity to sleep, with impaired daytime functioning. In neurological disease it may result from damage to sleep-regulating brain regions, from symptoms such as motor deficits, from comorbid pain, depression or anxiety, or from medications. The guideline covers headache, neurodegenerative movement disorders, multiple sclerosis, traumatic brain injury, epilepsy, neuromuscular disease, stroke and dementia.

Diagnosis and general treatment

The work-up should include a full medical and psychiatric history, physical examination, sleep questionnaires and a sleep diary, with review of substances that disturb sleep. Actigraphy can assess sleep-wake patterns over longer periods. Polysomnography is recommended when another sleep disorder is suspected, when insomnia is treatment-resistant or dangerous, or when subjective and objective findings disagree. Sleep hygiene should be assessed and improved, comorbid insomnia treated according to international insomnia guidelines, and a sleep specialist involved where needed.

Disease-specific recommendations

In headache, cognitive behavioral therapy for insomnia (CBT-I) is recommended alongside drug treatment. In Parkinson's disease, switching to extended-release dopaminergic therapy may improve sleep quality, and CBT-I, light therapy, melatonin and better sleep hygiene can be used, while other causes such as restless legs should be looked for and caregivers' sleep considered. Insomnia can precede multiple sclerosis by years; CBT-I and melatonin are recommended, with antidepressants for comorbid depression. After traumatic brain injury, symptom-oriented treatment combined with CBT-I is advised. In epilepsy, antiseizure drugs that do not disturb sleep should be preferred, and melatonin may shorten sleep latency in children. Insomnia should be considered in neuromuscular diseases such as ALS. After stroke, insomnia is common and should be screened for and treated with light therapy, benzodiazepine receptor agonists, sedating antidepressants, CBT-I or acupuncture.

Dementia

Long-term neuroleptics given for behavioral symptoms should be tapered. Hypnotics are generally not recommended in dementia, whereas melatonin, a sedating antidepressant and bright light therapy combined with regular walking are options in Alzheimer's disease. Most recommendations in the guideline rest on low-level evidence.