What medications are used to treat post-traumatic stress disorder (PTSD) nightmares?

Medications for PTSD-Associated Nightmares

Prazosin is the first-line pharmacotherapy for PTSD-associated nightmares, despite some contradictory evidence in recent studies. 1

First-Line Treatment: Prazosin

• Prazosin, an alpha-1 adrenergic antagonist, reduces central nervous system adrenergic activity that contributes to PTSD-related nightmares 1
• Starting dose is typically 1 mg at bedtime, with gradual increases by 1-2 mg every few days until an effective dose is reached 1
• Average effective dose is approximately 3 mg, though higher doses (9.5-13.3 mg/day) have been used in military veterans with good results 1, 2
• Some case reports document successful treatment with doses as high as 30-45 mg for treatment-resistant cases 3
• Treatment response may occur within one week of initiation 4
• The main side effect concern is orthostatic hypotension, requiring blood pressure monitoring 1, 4

Second-Line Options

• Clonidine (alpha-2 adrenergic receptor agonist) is a second-line option with dosing of 0.2-0.6 mg in divided doses 1
• Topiramate may be used for PTSD-associated nightmares 5
  • Typically started at 25 mg/day and titrated up to effect or maximum 400 mg/day 5
  • In one study, 79% of patients experienced reduced nightmares, with full suppression in 50% 5
  • Most responders achieved results with 100 mg/day or less 5
• Trazodone has shown efficacy in reducing nightmare frequency 5
  • Mean effective dose reported as 212 mg/day 5
  • Can reduce nightmare frequency from 3.3 to 1.3 nights/week 5
  • Side effects include daytime sedation, dizziness, and priapism 5

Other Medication Options

• Atypical antipsychotics (olanzapine, risperidone, aripiprazole) may be used for PTSD-associated nightmares 5
• Other options include cyproheptadine, fluvoxamine, gabapentin, nabilone, phenelzine, and tricyclic antidepressants 5
• For non-PTSD nightmare disorder specifically, nitrazepam and triazolam may be used 5
  • Both have shown equal effectiveness at reducing unpleasant dreams 5
  • Side effects include morning sedation and difficulty concentrating 5

Medications to Avoid

• Clonazepam is not recommended for nightmare disorder 5
  • Studies show no improvement in frequency or intensity of nightmares compared to placebo 5
• Venlafaxine is not recommended for nightmare disorder 5
  • Shows no significant difference from placebo in reducing distressing dreams 5, 1

Clinical Considerations

• PTSD-associated nightmares significantly impair quality of life, causing sleep avoidance, sleep deprivation, and daytime fatigue 1
• Successful treatment improves sleep quality, reduces daytime fatigue, and decreases insomnia symptoms 1
• Patients should maintain concurrent psychotherapy and other psychotropic medications during pharmacological treatment 1
• For patients with partial response to initial treatment, consider dose increases or combination therapy 3, 6
• Treatment response should be monitored using standardized measures such as the Clinician-Administered PTSD Scale (CAPS) 1, 7