In the absence of
sleep deprivation (either because of behavioral or medical causes) or pharmacologically induced
sleepiness,
hypersomnia is a manifestation of one of the central disorders of
hypersomnolence, such as
narcolepsy types 1 and 2,
idiopathic hypersomnia, and
recurrent hypersomnias such as
Kleine-Levin syndrome.
Narcolepsy and most primary
hypersomnias are
chronic conditions, thus, before committing an individual to chronic, possibly, life-long treatments, an accurate diagnosis is important. The key to effective management of
hypersomnia, thus, lies in a thorough history, detailed physical examination, and appropriate diagnostic tests. Secondary causes of
hypersomnia are expected to resolve once these disorders are treated. The treatment of central
hypersomnias, on the other hand, is guided by a level of diagnostic certainty as to the etiology of the
hypersomnia.
Narcolepsy, for example, has well defined pathophysiologic and diagnostic criteria, including low levels of
hypocretin in cerebrospinal fluid (CSF) and specific findings on a polysomnography/multiple sleep latency test (PSG/MSLT). For these patients, life-long
therapy is the norm and involves initiating treatment usually with
modafinil,
armodafinil, or
sodium oxybate, with
methylphenidate,
amphetamine-like stimulants,
atomoxetine, or
antidepressants used as second-line
therapy. Pharmacologic
therapy is usually done in concert with behavioral modifications such as scheduled napping for the best response. On the other hand, the etiology and pathophysiology of non-
hypocretin-related
hypersomnias (eg,
idiopathic hypersomnia, Kleine-Levine syndrome) are unknown. For these reasons, treatment of these disorders is more challenging and less well defined. A trial of
modafinil or
armodafinil may be considered as first line
therapy along with behavioral modifications.
Methylphenidate,
amphetamine-based stimulants, and even
clarithromycin have also been used. There is no effective cure for
hypersomnia, and the current
therapy is purely symptomatic. Thus, initial patient education, addressing treatment expectations, as well as continued regular follow-up to monitor treatment response are vital to effective management of
hypersomnia. The focus of this article is limited to a discussion of treatment of central disorders of
hypersomnolence.