From the Guidelines
When prazosin is ineffective for trauma nightmares, image rehearsal therapy (IRT) is a recommended first-line non-pharmacological option, as stated in the 2018 position paper for the treatment of nightmare disorder in adults 1. This approach involves patients rewriting and mentally rehearsing new, non-threatening versions of recurring nightmares. Other medication options that may be considered include:
- trazodone (50-200 mg at bedtime), which works through serotonergic and alpha-blocking properties
- clonidine (0.1-0.3 mg at bedtime), another alpha-adrenergic blocker that reduces nighttime norepinephrine
- atypical antipsychotics like olanzapine (2.5-10 mg at bedtime), which may help through multiple neurotransmitter effects, as suggested in the 2018 position paper 1
- cyproheptadine (4-12 mg at bedtime), an antihistamine with antiserotonergic properties, may help some patients, as mentioned in the 2018 position paper 1 These alternatives work by modulating the hyperarousal and fear responses associated with trauma nightmares through different neurochemical pathways. Combining medication with trauma-focused psychotherapy often yields better results than either approach alone, as therapy addresses the underlying trauma while medications manage the neurobiological dysregulation driving nightmares. It's worth noting that the most recent guideline from 2024 recommends use of specific manualized psychotherapies over pharmacotherapy for PTSD treatment, including prolonged exposure, cognitive processing therapy, or eye movement desensitization and reprocessing psychotherapy 1.
From the Research
Alternatives to Prazosin for Trauma Nightmares
If prazosin is ineffective in managing trauma nightmares, several alternative treatments can be considered:
- SSRIs: Selective serotonin reuptake inhibitors, such as sertraline, paroxetine, and fluoxetine, are effective in reducing PTSD symptoms, including nightmares 2.
- Non-SSRIs: Serotonin-potentiating non-SSRIs, such as venlafaxine, nefazodone, trazodone, and mirtazapine, have shown promising results in reducing PTSD symptoms, including nightmares 2.
- Anticonvulsants: Anticonvulsants, such as carbamazepine, valproic acid, topiramate, and gabapentin, have been evaluated in PTSD and may be effective in reducing nightmares, especially in patients with co-morbid bipolar disorder or impulsivity and anger issues 2.
- Atypical Antipsychotics: Atypical antipsychotics, such as quetiapine, have been shown to be effective in reducing PTSD symptoms, including nightmares, and may be considered as a second-line treatment or as an augmenter to SSRIs 3.
- Risperidone: Risperidone, an atypical antipsychotic, has been shown to be effective as an add-on therapy in patients who did not fully benefit from previous treatment with SSRIs 4.
Considerations for Treatment
When considering alternative treatments, it is essential to:
- Evaluate the patient's specific symptoms and needs
- Consider the potential benefits and risks of each treatment option
- Monitor the patient's response to treatment and adjust as needed
- Be aware of the potential for adverse effects, such as sedation, and take steps to minimize them 3