Over the years, I have relied on herbal formulas, melatonin, NyQuil (when sick), and — as you read here — one Tylenol PM per night while recovering from surgery. (Two and I’d never want to get out of bed.) My point of view on long-term use of sleeping pills, both OTC like Tylenol and prescription meds, was based on research I’d found working on the sleep chapter of The Power of 5 and various blog posts.
Then surgery happened, and so did the fog. Figuring out what was actually going on in my own head sent me back into the research — and I found a body of science that had moved well past what I thought I knew. My point of view needed an update.
What I found is that the landscape has shifted, and one new finding on melatonin deserves your attention.
The Study That Started This
A doctor I’ve had on the podcast — Dr. Ravi Kumar–, who’s coming back for a second conversation this month — recently published a look at long-term melatonin supplementation in adults with insomnia. Over 130,000 people. The finding: those who took melatonin nightly for a year or longer showed a 90% higher rate of heart failure diagnosis and nearly 3.5 times the rate of heart failure hospitalization, compared to non-users.
Before you panic, or before you decamp to the “supplements are all a scam” side, let’s break this down. First of all, the study is observational. It shows melatonin users and heart failure showed up together more often; it doesn’t prove melatonin caused it. People who struggle enough with sleep to take a supplement nightly for a year may already be dealing with health issues that raise cardiac risk on their own. And, chronic lack of sleep can also lead to greater risk of heart disease.
But here’s why it still matters: melatonin has been marketed — to you, specifically, as a woman managing sleep through hormonal transitions and beyond, as the “safe, natural” option. No warnings, no prescription, available in the same aisle as gummy vitamins. This study is a reminder that natural and consequence-free are not the same. Anything that changes your physiology nightly for years deserves the same scrutiny you’d give a prescription. It bummed me out, but not enough to give up my sleep gummies, which contain 3 mgs of melatonin. As an overall healthy person with no heart disease at present, I’m going with “sleep is more important for my heart health than not sleeping.” They do help me sleep.
What’s Actually New on the Prescription Side
The real shift in prescription sleep medicine over the past few years isn’t a new pill — it’s a new mechanism. Older sleep drugs, from benzodiazepines to Z-drugs* like Ambien, work by sedating your brain broadly.
*Z-drugs” is the informal name for a class of sleep medications that includes zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta) — the name comes from the fact that all three generic names start with Z.
They slow everything down, which is part of why next-day grogginess, falls, and cognitive fog are such common complaints, especially as we age.
The newer class — dual orexin receptor antagonists, or DORAs — works differently. Instead of sedating the brain broadly, they turn off the wakefulness signal itself: orexin, the chemical that’s telling your brain to stay alert. Three are currently approved: suvorexant (Belsomra), lemborexant (Dayvigo), and daridorexant (Quviviq). The pitch is less knock out, more removing the thing keeping you up — which in theory means less next-day impairment.
DORA side effects vs. older drugs
Side effects across the class are generally milder than what benzodiazepines and Z-drugs produce. The most common complaints with DORAs are daytime sleepiness, headache, and dizziness — occurring in a meaningful minority of users, but nothing close to the cognitive impairment, dependence, and fall risk documented with older options. A large network meta-analysis found no evidence that DORAs cause the physiological tolerance, withdrawal, or rebound insomnia that make stopping a benzodiazepine or Z-drug so difficult for long-term users. Benzodiazepines and Z-drugs remain on the Beers Criteria list — a widely used clinical guide flagging medications considered inappropriate for older adults — largely because of fall and fracture risk. That’s the real distinction worth understanding: it’s not that DORAs have zero side effects; it’s that the specific risks tied to aging (falls, memory disruption, difficult withdrawal) are substantially lower.
What’s Actually New Over the Counter
Short answer: no major new products. What’s changed is the warning volume, not the ingredient list.
If you’re still reaching for anything with diphenhydramine or doxylamine in it — that’s Benadryl, Unisom, Tylenol PM, ZzzQuil — the guidance against nightly use in adults over 60 has only gotten louder. These are anticholinergic drugs. Long-term use has been tied to increased dementia risk, and even short-term use raises fall risk because of how they linger in an aging metabolism. This is the exact mechanism I walked you through in “It Could Have Been Dementia” . I lived the confused, foggy version of what these medications can do.
The alternatives getting more attention: low-dose melatonin (0.5–3mg, not the 10mg mega-doses lining store shelves), magnesium glycinate, and L-theanine. None of them are magic and none carry the risks of that an antihistamine you weren’t supposed to take nightly in the first place. And CBT-I, cognitive behavioral therapy for insomnia — remains the actual gold standard, not a supplement at all.
Melatonin’s Unpredictable Track Record
This is worth its own paragraph: melatonin doesn’t work the same for everyone, and there’s a real reason. Your body makes its own melatonin on a schedule tied to light exposure and your internal clock. Supplementing adds to a system that’s already trying to regulate itself — and dosing is a mess. Many commercial melatonin products contain far more than the label states, sometimes five to ten times the amount your body would naturally produce in a night. If it’s worked wonders for you, worked mildly, or done nothing at all, that’s not a personal failure. That’s dose variability and individual chemistry doing exactly what they do.
Where This Leaves You
If you’re reading this and you’re currently taking Benadryl, Tylenol PM, or a prescription sleeping pill nightly, this isn’t a call to stop tonight. A few things worth knowing as you think it through:
Stopping some of these cold can backfire. Benzodiazepines and Z-drugs, taken nightly for months or years, can produce real physical dependence — stopping abruptly can cause rebound insomnia or withdrawal symptoms. This is a conversation for your doctor, not a solo project.
Write down what you’re actually taking, and why. Bring it to your next doctor’s appointment. Bring the exact name, dose, and how long you’ve used it nightly. Many people can’t answer the dose question off the top of their head, and it’s the single most useful thing you can hand a doctor who’s trying to help you transition to something safer.
Ask specifically about alternatives, by name. “DORA,” “CBT-I,” and “Beers Criteria” are now words you know. Doctors move faster with patients who show up with the right vocabulary — you’re not diagnosing yourself, you’re making sure the conversation doesn’t default to “just keep taking what you’re taking.”
I’ll be continuing this conversation with Dr. Kumar when he’s back on the podcast this month. We’ll go deeper into what the heart failure data does and doesn’t tell us — and what a genuinely evidence-based sleep protocol looks like for someone in your stage of life. More on that soon.
