What is the recommended treatment for sleep paralysis?

Treatment of Sleep Paralysis

The recommended treatment for sleep paralysis includes sodium oxybate, REM sleep suppressant medications (such as TCAs, SSRIs, venlafaxine), and behavioral modifications including meditation-relaxation therapy. 1

Pharmacological Interventions

First-line Medications

• Sodium oxybate can be used to treat sleep paralysis along with other symptoms of narcolepsy including disrupted nocturnal sleep and hypnagogic hallucinations. It is administered as a liquid in 2 divided doses at night - first at bedtime and second 2.5-4 hours later. Common side effects include headaches, nausea, unexpected neuropsychiatric effects, and fluid retention. 1

• REM sleep suppressant medications have shown efficacy in treating sleep paralysis:

  • Tricyclic antidepressants (TCAs)
  • Selective serotonin reuptake inhibitors (SSRIs)
  • Venlafaxine
  • Reboxetine 1

• Escitalopram, the most selective SSRI, has been reported to successfully treat recurrent isolated sleep paralysis while generally improving subjective sleep quality. 2

Caution with Medications

• Careful monitoring is necessary when starting or adjusting medication doses, particularly for adverse effects including hypertension, palpitations, arrhythmias, irritability, or behavioral manifestations such as psychosis. 1
• Paradoxically, some SSRIs like sertraline have been reported to induce sleep paralysis in certain patients, highlighting the importance of monitoring for this potential side effect. 3

Non-Pharmacological Approaches

Meditation-Relaxation (MR) Therapy

• MR therapy has shown promising results in reducing sleep paralysis frequency. In a pilot study with narcolepsy patients, 8 weeks of MR therapy resulted in a 50% reduction in the number of days sleep paralysis occurred and a 54% reduction in total episodes. 4

Behavioral Modifications

• Maintain good sleep hygiene techniques and a regular sleep-wake schedule allowing adequate time for nocturnal sleep. 1
• Avoid heavy meals throughout the day and alcohol use. 1
• Schedule two short 15-20 minute naps - one around noon and another around 4:00-5:00 pm to alleviate sleepiness that may contribute to sleep paralysis. 1
• For employed patients, avoid shiftwork, on-call schedules, and jobs requiring continuous attention for long hours without breaks. 1

Prevention and Disruption Techniques

• Many individuals develop their own techniques to prevent or disrupt sleep paralysis episodes:
  • About 19% of affected individuals attempt prevention techniques, with 79% reporting success. 5
  • Nearly 69% attempt disruption techniques during episodes, with 54% finding them effective. 5
• Teaching patients specific prevention and disruption techniques may be an effective management strategy for problematic sleep paralysis. 5

Clinical Management Approach

Diagnosis and Assessment

• Sleep paralysis should be considered when excessive sleepiness is accompanied by cataplexy, frequent short naps, vivid dreams, disrupted sleep, or sleep paralysis itself. 1
• Multiple sleep latency tests (MSLTs) and polysomnography (PSG) can be useful in diagnosing narcolepsy and associated sleep paralysis. 1

Follow-up and Monitoring

• Regular follow-up is essential as most hypersomnias of central origin (including those with sleep paralysis) are long-term or lifelong disorders requiring ongoing management. 1
• The Epworth Sleepiness Scale (ESS) is a useful tool for monitoring subjective sleepiness and response to therapy at each visit. 1
• Once symptoms are stable, any future exacerbation of symptoms (including sleep paralysis) should be evaluated formally by history, physical examination, and/or repeat PSG. 1

Referral Considerations

• Primary care physicians should refer patients to a sleep specialist when narcolepsy is suspected or the cause of sleep paralysis is unknown. 1
• Complex patients who are unresponsive to initial or subsequent therapy may benefit from a sleep specialist consultation. 1
• Support services and groups such as the Narcolepsy Institute or the National Sleep Foundation can provide helpful resources. 1

Special Considerations

• Sleep paralysis can be particularly distressing, with approximately 76% of sufferers experiencing fear during episodes and 15% experiencing clinically significant distress or interference with daily life. 5
• Patient education about the nature of REM sleep and how dream enactment and paralysis occur is a critical first step in management, helping patients address distress and maintain treatment strategies. 1
• For isolated sleep paralysis without narcolepsy, cognitive and behavioral therapies are first-line treatments, with pharmacologic interventions reserved for more severe or treatment-resistant cases. 6