What medications are used to treat night terrors?

Medications for Night Terrors

For night terrors, Image Rehearsal Therapy (IRT) is recommended as first-line treatment, while prazosin may be used as the primary pharmacological option when medication is needed. 1, 2

Pharmacological Treatment Options

First-line Pharmacological Options:

• Prazosin:
  • Start at 1 mg at bedtime
  • Titrate by 1-2 mg every 3-7 days
  • Typical effective dose: 1-10+ mg
  • Monitor for orthostatic hypotension, especially after first dose 2

Other Medications That May Be Used:

• Clonidine:

  • Starting dose: 0.1 mg twice daily
  • Titrate as needed
  • Monitor for blood pressure changes 2

• Benzodiazepines (short-term use only):

  • Triazolam may be used for nightmare disorder 1
  • Nitrazepam may be used for nightmare disorder 1
  • Clonazepam is specifically not recommended due to ineffectiveness 1, 2
  • Note: Long-term benzodiazepine use is discouraged due to addiction potential and relapse of symptoms 3

• Other medications that may be considered:

  • Atypical antipsychotics (olanzapine, risperidone, aripiprazole) 1, 2
  • Cyproheptadine 1
  • Fluvoxamine 1
  • Gabapentin 1
  • Nabilone 1, 4
  • Phenelzine (use with caution due to MAOI risks) 1
  • Topiramate 1, 2
  • Trazodone 1, 2
  • Tricyclic antidepressants 1

Medications to Avoid:

• Clonazepam - not recommended for nightmare disorder 1
• Venlafaxine - not recommended for nightmare disorder 1

Non-Pharmacological Approaches

First-line Non-Pharmacological Treatment:

• Image Rehearsal Therapy (IRT) - highest level of recommendation 1, 2, 4

Other Non-Pharmacological Options:

• Cognitive Behavioral Therapy (CBT) 1, 2, 4
• Exposure, Relaxation, and Rescripting Therapy (ERRT) 1, 2, 4
• Eye Movement Desensitization and Reprocessing (EMDR) 1, 2
• Hypnosis 1, 5
• Lucid dreaming therapy 1
• Progressive deep muscle relaxation 1
• Sleep dynamic therapy 1
• Self-exposure therapy 1
• Systematic desensitization 1
• Anticipatory awakening (for children) 6

Treatment Algorithm

1. Start with non-pharmacological approach:

   • Image Rehearsal Therapy as first-line treatment
   • Ensure good sleep hygiene and appropriate sleeping environment 6

2. If non-pharmacological approach is insufficient after 4-6 weeks:

   • Add pharmacological treatment
   • Prazosin is typically the first medication to try

3. If combined approach fails:

   • Consider alternative medications like clonidine or atypical antipsychotics 2

Special Considerations

• For children: Most children outgrow night terrors by late adolescence 6
• For PTSD-related nightmares: Consider combining CBT for insomnia with IRT or ERRT 4
• Monitoring: Assess nightmare frequency and intensity using standardized measures or sleep diaries 2

Common Pitfalls to Avoid

• Underdosing prazosin
• Failing to monitor blood pressure during medication treatment
• Discontinuing treatment prematurely
• Relying solely on pharmacological treatment without implementing non-pharmacological approaches
• Using medications specifically not recommended (clonazepam, venlafaxine) 2
• Attempting to interrupt a sleep terror episode (should be avoided) 6