Purpose of Review <p>Pre-sleep anxiety is a transdiagnostic contributor to difficulty initiating sleep that is maintained through interconnected cognitive, physiological, and neurobiological processes. This narrative review synthesizes current evidence on the mechanisms underlying pre-sleep anxiety and evaluates behavioral interventions across clinical populations.</p> Recent Findings <p>Key mechanisms implicated in pre-sleep anxiety include pre-sleep worry, rumination, conditioned arousal, autonomic dysregulation, and brain network alterations involved in threat detection and cognitive control. Evidence-based interventions include cognitive behavioral therapy for insomnia (CBT-I), mindfulness and acceptance-based approaches, relaxation strategies, and environmental optimization. Clinical considerations vary across individuals with comorbid anxiety disorders, developmental stages, and cultural contexts. Digital delivery formats have emerged as scalable approaches to extend treatment access. However, much of the existing evidence is derived from broader insomnia populations rather than pre-sleep anxiety as a distinct construct, limiting mechanistic specificity. </p> Summary <p>This review provides an integrative framework linking mechanisms to evidence-based interventions for pre-sleep anxiety across diverse clinical populations and settings. Future research directions include mechanistic trials integrating objective biomarkers with clinical outcomes, component optimization studies, and scalable implementation approaches. </p>