What is the treatment for night terrors?

Treatment for Night Terrors

Image rehearsal therapy is the recommended first-line treatment for night terrors, with behavioral interventions being the mainstay of management rather than pharmacological approaches. 1

Understanding Night Terrors

Night terrors are episodes of intense fear, screaming, and agitation that occur during the first third of the night, typically during non-REM sleep stages 3-4. They differ from nightmares in that:

• The person remains partially asleep during the episode
• There is typically amnesia for the event the next morning
• Autonomic hyperactivity is present (tachycardia, tachypnea, diaphoresis)
• The person is difficult to console or awaken during the episode

Non-Pharmacological Treatments (First-Line)

Recommended Approaches:

1. Image Rehearsal Therapy (IRT)

   • Most strongly recommended treatment based on evidence 1
   • Involves recalling the terror, writing it down, changing the theme to a more positive one
   • Practice the rewritten scenario for 10-20 minutes daily while awake
   • Shown to reduce frequency and intensity of episodes

2. Sleep Hygiene Optimization

   • Maintain consistent sleep-wake schedule
   • Ensure adequate sleep duration (sleep deprivation can trigger episodes)
   • Create a calm, quiet sleeping environment

3. Anticipatory Awakening

   • Wake the person approximately 30 minutes before the typical time of night terror
   • Particularly effective for predictable, frequently occurring episodes 2
   • Keep the awakening brief, then allow return to sleep

4. Other Behavioral Approaches That May Be Used:

   • Cognitive Behavioral Therapy
   • Progressive deep muscle relaxation
   • Systematic desensitization
   • Hypnosis (in appropriate cases)

Pharmacological Treatments (Second-Line)

Medications should be considered only when:

• Night terrors are frequent and severe
• Episodes cause significant functional impairment
• Behavioral approaches have failed

Medication Options:

1. Clonazepam

   • May be considered for short-term use in severe cases 2
   • Important caveat: The 2018 AASM position paper specifically states clonazepam is NOT recommended for nightmare disorder 1
   • Risk of dependence with prolonged use 3
   • Should be tapered gradually when discontinuing

2. Prazosin

   • May be used for treatment of night terrors, particularly those associated with PTSD 1
   • Starting dose: 1mg at bedtime, gradually increased as needed
   • Monitor for orthostatic hypotension

Special Considerations

Duration of Treatment

• Most children outgrow night terrors by late adolescence 2
• Treatment is typically short-term until episodes resolve
• Regular reassessment is necessary for those on medication

When to Refer

• When episodes are associated with:
  • Daytime impairment
  • Risk of injury
  • Psychological distress
  • Suspected underlying medical condition

Common Pitfalls to Avoid

1. Do not attempt to awaken or interrupt an ongoing night terror episode

   • This may increase agitation and prolong the episode
   • Instead, ensure safety by gently guiding the person away from harm

2. Avoid overmedication

   • Pharmacological treatment should be short-term and targeted
   • Drug therapy is almost never necessary as first-line treatment 4

3. Don't confuse night terrors with nightmares

   • Nightmares occur during REM sleep and are remembered
   • Night terrors occur during non-REM sleep with amnesia for the event

4. Don't overlook potential triggers

   • Stress, fever, sleep deprivation
   • Sleep-disordered breathing
   • Certain medications

The natural history of night terrors tends toward spontaneous resolution, with 50% of cases resolving by age 8 and most others by adolescence 5. Reassurance about the benign nature of the condition is an important part of management.