Difficulty initiating / maintaining sleep ≥3 nights/week for ≥3 months with daytime impairment.
Etiology
- • Primary or secondary (anxiety, depression, OSA, RLS, drugs, caffeine, pain)
History taking
- • Onset, duration, progression, severity
- • Aggravating / relieving factors
- • Past history, drugs, allergies, comorbidities
- • Family & social history relevant to presentation
Examination
- • General: vitals, pallor, icterus, oedema, lymphadenopathy
- • Focused system examination
- • Look for red-flag findings
Red flags
- • Haemodynamic instability
- • Rapid deterioration
- • Severe pain or new neurological deficit
Differential diagnosis
- • See differentials section per chief complaint
Recommended investigations
- • CBC, basic metabolic panel as indicated
- • Targeted disease-specific tests
Diagnosis
- • Clinical diagnosis supported by targeted investigations
Initial treatment / management
- • CBT-I first-line
- • Treat underlying cause
Drug therapy
- • Short course (≤2 weeks) zolpidem 5–10 mg ON or melatonin 2 mg ON if >55 y
Lifestyle advice
- • Sleep hygiene: regular schedule, no screens 1 h before bed, no caffeine after midday
- • Stimulus control
Follow-up advice
- • Review in 2–4 weeks or earlier if worsening
- • Monitor response to therapy and adverse effects
Patient counselling
- • Explain diagnosis and natural course in lay terms
- • Red-flag symptoms warranting urgent return
- • Adherence to medications and follow-up
Referral criteria
- • Refer if diagnostic uncertainty, complications, or failure of first-line therapy
Clinical pearls
- • Avoid long-term benzodiazepines
References
- • Harrison's Principles of Internal Medicine, 21e
- • NICE / WHO guidelines (current edition)
Educational outpatient guide — verify against local guidelines before clinical use.
