What alternative medication can be used for nightmares in a patient who is not responding to prazosin (an alpha-1 adrenergic receptor blocker)?

Alternative Medications for Nightmares After Prazosin Failure

For patients who continue to experience nightmares despite prazosin therapy, trazodone (50-200 mg nightly) is the recommended alternative medication based on its effectiveness in reducing nightmare frequency and improving both sleep onset and maintenance. 1

Treatment Algorithm for Nightmare Management

1. First-line approach (already tried):

   • Prazosin (1-10+ mg daily) - Patient reports this is not working

2. Second-line pharmacological options:

   • Trazodone (50-200 mg nightly)

     • Decreases nightmare frequency from 3.3 to 1.3 nights/week in 72% of patients
     • Helps with both sleep onset (92% of patients) and sleep maintenance (78% of patients)
     • Start at 50mg at bedtime and titrate as needed
     • Mean effective dose is 212 mg/day 1

   • Clonidine (0.1-0.6 mg daily)

     • Start at 0.1 mg twice daily and titrate as needed
     • Level C recommendation from the American Academy of Sleep Medicine 1

3. Other medication options to consider:

   • SSRIs (sertraline, paroxetine, fluoxetine) - particularly if underlying panic disorder is present
   • Atypical antipsychotics (olanzapine, risperidone, aripiprazole)
   • Other options: cyproheptadine, gabapentin, topiramate 1

Important Considerations

Medication Monitoring

• For trazodone:

  • Monitor for daytime sedation or dizziness (occurs in 60% of patients)
  • For male patients, specifically ask about priapism (occurs in 12% of patients)
  • Other side effects: dry mouth/sinuses, muscle pain, agitation 1

• For clonidine:

  • Monitor blood pressure regularly
  • Watch for orthostatic hypotension, especially after first dose 1

Medications to Avoid

• Benzodiazepines (including clonazepam) - lack of efficacy, risk of addiction, potential for relapse
• Venlafaxine - not recommended for nightmare disorder 1

Augmenting Pharmacotherapy

While switching medications, consider reinforcing these non-pharmacological approaches:

• Image Rehearsal Therapy (IRT) - Level A evidence
• Cognitive Behavioral Therapy (CBT)
• Sleep hygiene practices
• Regular sleep-wake schedule
• Avoiding alcohol and heavy meals 1

Common Pitfalls to Avoid

• Underdosing the alternative medication
• Discontinuing treatment prematurely (before adequate trial)
• Relying solely on pharmacological treatment without behavioral approaches
• Failing to monitor side effects specific to each medication 1

Remember to track nightmare frequency and intensity using sleep diaries to objectively assess the effectiveness of the new medication regimen 1.