What are the treatment options for parasomnias, including sleepwalking and night terrors?

From the Guidelines

Treatment for parasomnias, including sleepwalking and night terrors, should prioritize improving sleep hygiene and may involve medications such as benzodiazepines or antidepressants, as well as non-pharmacological approaches like cognitive behavioral therapy for insomnia (CBT-I) and scheduled awakenings. When considering treatment options, it's essential to assess the individual's specific parasomnia type, frequency, and severity, as well as their age and any underlying psychological factors that may be contributing to the condition 1. Some key strategies for managing parasomnias include:

• Improving sleep hygiene by maintaining a regular sleep schedule, reducing stress, and avoiding alcohol and sedatives
• Ensuring a safe sleeping environment by removing hazards and possibly installing door alarms
• Using medications such as benzodiazepines (e.g., clonazepam 0.5-2mg at bedtime) or antidepressants (e.g., paroxetine 10-40mg daily or trazodone 50-100mg at bedtime) to suppress deep sleep or address underlying psychological issues
• Utilizing non-pharmacological approaches like CBT-I to address underlying sleep issues or scheduled awakenings to interrupt predictable parasomnias
• Considering the use of melatonin (3-10mg before bed) to help regulate sleep cycles in some patients. It's crucial to individualize treatment based on the patient's specific needs and circumstances, taking into account the potential benefits and risks of each approach, as well as the patient's preferences and values 1.

From the Research

Treatment Options for Parasomnias

The treatment options for parasomnias, including sleepwalking and night terrors, are varied and can be categorized into nonpharmacological and pharmacological interventions.

• Nonpharmacological interventions include:
  • Cognitive-behavioral therapy (CBT) 2, 3
  • Hypnosis 3
  • Relaxation techniques 2, 3
  • Sleep hygiene 4, 3
  • Scheduled awakenings 3
  • Sleep extension/scheduled naps 3
  • Mindfulness 3
  • Education and reassurance 3
• Pharmacological interventions include:
  • Alpha-blockers (prazosin) 2
  • Tricyclic antidepressants (imipramine and clomipramine) 2
  • Selective serotonin reuptake inhibitors 2
  • Benzodiazepines (diazepam and clonazepam) 2, 4
  • Anticonvulsants (topiramate and gabapentin) 2
  • Desmopressin acetate 2
  • Anticholinergic agents (oxybutynin and tolterodine) 2
  • Melatonin 4

Efficacy of Treatments

The efficacy of these treatments varies, with some studies showing promising results for nonpharmacological interventions such as CBT, hypnosis, and sleep hygiene 4, 3. However, the evidence is limited by the retrospective and uncontrolled nature of most research, as well as the infrequent use of validated quantitative outcome measures 3. Pharmacological interventions have also shown efficacy, but their use is often limited by side effects and the risk of dependence 5.

Approach to Treatment

The approach to treatment for parasomnias often involves a combination of nonpharmacological and pharmacological interventions, with a focus on addressing underlying sleep disorders and priming factors such as stress and anxiety 4. A hierarchical approach to treatment, starting with sleep hygiene and education, followed by nonpharmacological interventions, and finally pharmacological interventions, may be effective in managing parasomnias 4.