What medications are effective for treating nightmares?

Medications for Treating Nightmares

Prazosin is the most effective medication for treating nightmares, particularly those associated with PTSD, and should be considered the first-line pharmacological treatment option. 1

First-Line Treatment Options

Non-Pharmacological Treatment

• Image Rehearsal Therapy (IRT) is the most strongly recommended first-line non-pharmacological treatment for nightmares with Level A evidence 1
  • Involves recalling the nightmare, rewriting it with a positive outcome, and mentally rehearsing the new version
  • Reduces nightmare frequency by 60-72% with maintained effects at follow-up
  • Should be considered alongside pharmacological treatment

Pharmacological Treatment: Prazosin

• Dosing and Administration:

  • Starting dose: 1 mg at bedtime 2, 1
  • Gradual titration: Increase by 1-2 mg every 3-7 days until effective 1
  • Typical effective doses:
    • Average dose: ~3 mg (range 1-10+ mg) 2
    • Military veterans often require higher doses (9.5-15.6 mg/day) 1
    • Women typically respond to lower doses (average 7.0 mg) than men (average 15.6 mg) 1

• Mechanism of Action:

  • Alpha-1 adrenergic receptor antagonist 3
  • Blocks elevated CNS noradrenergic activity associated with PTSD symptoms 2, 1
  • Norepinephrine plays a key role in PTSD-related nightmares, arousal, and vigilance 2

• Efficacy:

  • Level A evidence for PTSD-associated nightmares 2, 1
  • Multiple randomized controlled trials show significant reduction in trauma-related nightmares 2, 4
  • Treatment effect can be seen within weeks 5

• Monitoring:

  • Monitor for orthostatic hypotension, especially after first dose and during titration 2, 1
  • Assess response after 4-6 weeks at maximum tolerated dose 1

Second-Line Medication Options

Clonidine

• Alpha-2 adrenergic receptor agonist that suppresses sympathetic nervous system outflow 2
• Level C evidence for PTSD-associated nightmares 2
• Dosage: 0.2-0.6 mg (in divided doses) 2
• Similar mechanism to prazosin but with less robust evidence 2
• Monitor for blood pressure changes

Other Medication Options (Level C Evidence) 2, 1

• Trazodone

  • Shown to decrease nightmares in 72% of veterans (from 3.3 to 1.3 nights per week)
  • Dosage range: 25-600 mg (mean 212 mg)
  • Common side effects: daytime sedation, dizziness, headache, priapism, orthostatic hypotension

• Atypical Antipsychotics

  • Olanzapine (10-20 mg)
  • Risperidone (1-3 mg/day)
  • Consider for treatment-resistant cases

• Other options with limited evidence:

  • Topiramate
  • Low-dose cortisol (10 mg/day)
  • Fluvoxamine
  • Triazolam and nitrazepam
  • Gabapentin
  • Cyproheptadine

Treatment Algorithm

1. Initial Assessment:

   • Determine if nightmares occur at least weekly and cause significant distress
   • Assess for PTSD or other underlying conditions
   • Use standardized measures like CAPS or sleep diaries to monitor frequency and intensity

2. First-Line Treatment:

   • Begin Image Rehearsal Therapy (IRT) if available
   • For PTSD-associated nightmares or when medication is needed, start prazosin at 1 mg at bedtime
   • Monitor blood pressure after first dose
   • Gradually increase prazosin by 1-2 mg every 3-7 days

3. Dose Optimization:

   • For civilian patients: Aim for 3-7 mg
   • For military veterans: May require 9.5-15.6 mg
   • Continue titration until nightmares improve or side effects limit further increases

4. For Partial Response:

   • Combine IRT with medication therapy
   • Ensure adequate prazosin dosing (avoid underdosing, especially in veterans)

5. For Inadequate Response:

   • Consider adding clonidine (0.2-0.6 mg in divided doses)
   • Alternative options: trazodone, atypical antipsychotics, or topiramate

Common Pitfalls to Avoid

• Underdosing prazosin, particularly in male veterans who typically require higher doses 1
• Discontinuing treatment prematurely before adequate dose titration 1
• Not monitoring blood pressure when initiating prazosin therapy 1
• Overlooking non-pharmacological treatments like IRT which has strong evidence 1
• Using medications not recommended for nightmare disorder, such as clonazepam and venlafaxine 1
• Not considering medication interactions with other psychotropic medications the patient may be taking

Prazosin has consistently demonstrated efficacy in multiple studies, with most patients experiencing significant improvement in nightmare frequency and intensity 4, 6, 7, 8. Its favorable side effect profile and effectiveness make it the clear first-choice medication for treating nightmares, particularly those associated with PTSD.