Two of the most common insomnia treatments are hydroxyzine and trazodone. Both are prescribed off-label for sleep, both are non-habit-forming, and neither is a controlled substance, which makes them effective alternatives to traditional sedatives.

But the two medications are not the same. Here is how they compare, so you can have a more informed conversation with your healthcare provider.

• Hydroxyzine is a first-generation antihistamine; trazodone is an atypical antidepressant.

• Both are used off-label to treat insomnia, and neither is a controlled or habit-forming substance.

• They share some common side effects but effect the body and treat insomnia differently.

• Hydroxyzine may be best for short-term insomnia treatment, while trazodone may be preferred for those with overlapping anxiety or depression.

What is hydroxyzine (generic Atarax^®, Vistaril^®)?

Hydroxyzine is a first-generation antihistamine that is FDA approved to treat anxiety, itching from allergic skin conditions and to provide sedation before or after surgery. It is not FDA approved as an insomnia treatment, but providers often prescribe it off-label for sleep because it causes drowsiness.

Hydroxyzine works mainly by blocking H1 histamine receptors in the brain. Histamine is one of the chemicals that keeps you alert and awake, so quieting it helps ease you toward sleep. Unlike some sleep aids, hydroxyzine is not a controlled substance and is not considered habit-forming, which is a big part of its appeal for people who want to avoid medications that carry a risk of dependence.^1,2

What is trazodone (generic Desyrel^®)?

Trazodone is an atypical antidepressant in a class called serotonin antagonist and reuptake inhibitors, or SARIs. It is FDA approved to treat depression but is also prescribed off-label for insomnia.

Trazodone works by blocking serotonin, histamine and alpha-1 receptors in the brain, which normally promote wakefulness. This produces a calming, sedating effect. Like hydroxyzine, trazodone is not a controlled substance and has a low risk of addiction, which makes it a popular option for longer-term sleep support.³

What are the differences between hydroxyzine and trazodone?

Although both medications can help you fall asleep, they belong to different drug classes and behave differently in the body.

• Hydroxyzine is a fast-acting antihistamine with a relatively long half-life.⁴

• Trazodone is an antidepressant that acts on serotonin and clears the body more quickly at sleep doses.⁵

Those differences impact how fast each one works, how long it lasts, who it suits best and what side effects to watch for. This chart breaks down key differences.^6,7

How effective are hydroxyzine and trazodone for insomnia and sleep disorders?

Hydroxyzine has been found to shorten the time it takes to fall asleep and improve sleep quality in the short term, though it appears to be more effective at helping people fall asleep than maintaining sleep throughout the night. It usually begins to work within 15 to 30 minutes. Because its effects weaken as your body gets used to the drug, it is typically prescribed for short-term treatment.^8,9

In multiple clinical trials, trazodone has shown to be effective in improving sleep latency (time to fall asleep) and sleep quality. Trazodone has also been shown to improve daytime cognitive functioning in multiple studies by improving sleep quality. It usually begins to work within 30 minutes to two hours after taking it.^10,11,12

Can hydroxyzine and trazodone be taken together for insomnia and sleep disorders?

In rare cases, yes. However, most of the time hydroxyzine and trazodone are not taken together because doing so can increase the risk of an irregular heart rhythm. You may be more susceptible to this risk if you have a heart condition called congenital long QT syndrome, other cardiac diseases, conduction abnormalities or electrolyte disturbances (for example, magnesium or potassium loss due to severe or prolonged diarrhea or vomiting).¹³

If your current medication is not working well, the safest choice is to talk with your provider about other options.

How should hydroxyzine and trazodone be taken for insomnia and sleep disorders?

Both medications are taken by mouth, once nightly, about 30 minutes before you plan to sleep. Take either medication only when you can devote a full night to sleep. Always follow all instructions from your healthcare provider, and never change your dose without consulting with your provider first.^14,15

How do side effects and safety compare for hydroxyzine and trazodone?

Hydroxyzine and trazodone share some common side effects, but their safety profiles differ because they work in differently and are often used for different reasons.

Common side effects when you taking hydroxyzine are typically mild. Examples of mild side effects that have been reported with hydroxyzine include:

• Nausea

• Weakness

• Drowsiness

• Headache

• Dizziness

• Dry mouth

• Confusion

• Mild allergic reaction

In rare cases, people may have serious side effects from taking hydroxyzine. Serious side effects that have been reported with hydroxyzine include:

• Cardiac (heart-related) side effects

• Skin reactions, such as a serious rash

• Tremors

• Convulsions

• Uncontrolled movements

• Severe allergic reaction

With hydroxyzine, older adults are more likely to experience sleepiness and confusion.¹⁶

Trazodone shares some common side effects, and like hydroxyzine, they are usually manageable. Shared side effects include:

• Drowsiness

• Dizziness

• Dry mouth

• Nausea

• Headache

Unlike hydroxyzine, trazodone may cause:

• Blurred vision

• Swelling of the face, hands or lower legs

• Nasal congestion

• Diarrhea or constipation

• Weight loss or weight gain

Another difference from hydroxyzine is that trazodone may cause sexual issues. In some cases, both men and women have reported an increased sex drive, while males may also experience erectile dysfunction, a dry ejaculation or priapism (a painful, prolonged erection lasting longer than four hours).¹⁷

How do costs and insurance coverage compare for hydroxyzine and trazodone?

Both hydroxyzine and trazodone have been available as generics for years, which makes them two of the more affordable prescription options for sleep. Through RedBox Rx, costs without insurance are:

• Hydroxyzine: $18.33 per month (with purchase of a three-month supply).

• Trazodone: $25 per month (with purchase of a three-month supply).

Costs will also include an online insomnia consultation with RedBox Rx for just $35. RedBox Rx accepts HSA and FSA payments for these treatments.

When doctors prescribe hydroxyzine vs. trazodone for sleep

According to Dr. Fick, chief medical officer for RedBox Rx’s parent company, Hy-Vee, Inc., a few factors typically guide that decision. Talk with your provider about:¹⁸

• How long you expect to need treatment: Hydroxyzine tends to lose effectiveness over time, so it is often chosen for short-term sleep support, while trazodone may be a better fit for ongoing use.

• Whether you also have anxiety or depression: Because trazodone is an antidepressant, it may help address overlapping anxiety or depression at the same time, whereas hydroxyzine is aimed at sleep alone.

• How quickly you want to fall asleep: Hydroxyzine generally works within 15 to 30 minutes, while trazodone can take anywhere from 30 minutes to two hours to take effect.

• Your other medications and health history: Combining certain medications can raise the risk of an irregular heart rhythm, so your provider will review everything you take and any heart-related conditions before recommending one.

• Which side effects concern you most: The two medications have overlapping but distinct side-effect profiles, so your provider may weigh which you are most likely to tolerate well.

“There’s no single right answer for everyone. I look at how long someone needs help sleeping, whether anxiety or depression is part of the picture, and what else they’re taking, and we choose the option that fits their life best.” – Dr. Fick, RedBox Rx

Your RedBox Rx consult will consider several factors before recommending one over the other, which is why an online telehealth consult can help you find the best option.

How RedBox Rx can help

RedBox Rx makes receiving treatment for insomnia easy and affordable, including low-cost prescriptions for proven sleep options like hydroxyzine and trazodone. We offer secure, private online consultations with licensed providers focused on your health.

Benefits of RedBox Rx include:

• Transparent, affordable, flat rates for insomnia medications starting at $18.33 per month.

• $35 consultation with a U.S. licensed medical professional.

• No insurance required. FSA and HSA eligible.

• No office wait times or scheduling issues typical with physical medical practices.

• FREE shipping directly to you. One-time, monthly and quarterly subscriptions available.

Get started on your insomnia treatment journey with our online assessment.