Recommended Medication for Treating Nightmares
Prazosin is recommended as the first-line pharmacological treatment for nightmares, particularly those associated with PTSD, with a starting dose of 1 mg at bedtime gradually increased to an effective dose (typically 3-15 mg). 1, 2
Prazosin Therapy Protocol
- Prazosin, an alpha-1 adrenergic antagonist, reduces central nervous system adrenergic activity that contributes to nightmare formation 2
- Start with 1 mg at bedtime and increase by 1-2 mg every few days until effective dose is reached 1, 2
- Average effective dose is approximately 3 mg, though doses ranging from 1-15 mg have shown efficacy 1
- Higher doses (9.5-13.3 mg/day) may be needed for military veterans with PTSD-associated nightmares 1, 2
- Monitor for orthostatic hypotension, especially after the first dose 1, 2
- Treatment duration in studies ranged from 3-9 weeks with maintained improvement 2, 3
Evidence Supporting Prazosin
- Multiple Level 1 placebo-controlled studies demonstrated significant reduction in trauma-related nightmares 1
- Studies included Vietnam combat veterans, military veterans, and civilian trauma victims 1
- Prazosin significantly reduced "recurrent distressing dreams" as measured by CAPS (Clinician-Administered PTSD Scale) 1, 2
- Nightmare suppression can occur within one week of prazosin initiation 4
- Recent evidence has led to a downgrading of the recommendation strength, but prazosin remains the first choice for pharmacologic therapy 1
Alternative Medications
- Topiramate may be considered as a second-line option, starting at 25 mg/day and titrating up to effect or maximum 400 mg/day 1, 2
- Trazodone has shown efficacy at a mean dose of 212 mg/day, reducing nightmare frequency from 3.3 to 1.3 nights/week 1, 2
- Other options with limited evidence include clonidine, atypical antipsychotics, and low-dose cortisol 2
- Avoid clonazepam, as studies show no improvement in frequency or intensity of nightmares compared to placebo 1
- Venlafaxine is not recommended as it shows no significant difference from placebo in reducing distressing dreams 1, 2
Clinical Considerations
- Untreated nightmares significantly impair quality of life, causing sleep avoidance, sleep deprivation, and daytime fatigue 1, 2
- Successful treatment improves sleep quality, reduces daytime fatigue, and decreases insomnia symptoms 1, 2
- Patients may maintain concurrent psychotherapy and other psychotropic medications during prazosin treatment 1, 5
- There may be interactions between prazosin and antidepressant medications that require further investigation 1
- Prazosin has shown efficacy in both combat-related and non-combat-related trauma nightmares 4, 6
Common Pitfalls and Caveats
- First-dose hypotension is a concern; consider administering the first dose when the patient can remain recumbent 2, 4
- Response to prazosin may be reduced in patients taking selective serotonin reuptake inhibitors 1
- Side effects of prazosin include orthostatic hypotension, dizziness, and headache 7, 4
- Trazodone side effects include daytime sedation, dizziness, and priapism (which occurred in 5 subjects in one study) 1
- Benzodiazepines should be avoided as they have not shown efficacy for nightmare treatment 1