Objective: To investigate the effect of treating insomnia and internal blockage of blood stasis in the elderly after stroke with acupuncture. Methods: 108 elderly patients with insomnia and internal stasis syndrome after stroke in our hospital from August 2022 to June 2024 were selected as the research objects according to the random number table method. 54 cases in group A were given repeated transcranial magnetic stimulation treatment, and 54 cases in group B were added the acupuncture method of eliminating stasis and relaxing the mind on the basis of group A. The clinical efficacy, TCM symptom score, sleep quality, neurotransmitter level and hemorheology were compared between the two groups. Results: After treatment, the total effective rate of group B was 83.33% (45/54) higher than that of group A (64.81% (35/54) (P < 0.05). The scores of TCM symptoms in group B were lower than those in group A (P<0.05). The scores of Pittsburgh sleep quality Index (PSQI) in all dimensions were increased in both groups, and group B was higher than group A (P <0.05). The expression levels of 5-hydroxyindoleacetic acid (5-HIAA) and 5-hydroxytryptamine (5-HT) in group B were higher than those in group A (P<0.05). Hemorheological indexes of systolic peak blood flow velocity (PSV), end-diastolic blood flow velocity (EDV) and time average flow velocity (TMFV) were increased in both groups, and those in group B were higher than those in group A (P<0.05). Conclusion: The treatment of acupuncture for relieving stasis and calming the spirit can improve the sleep quality and therapeutic effect of elderly patients with insomnia due to internal blood stasis syndrome after stroke, improve the adverse symptoms and arterial blood circulation, and promote the repair of nerve function defect.