From the Guidelines
Cyproheptadine is not recommended as a first-line treatment for PTSD-related nightmares due to conflicting and limited evidence of its effectiveness, as reported in a 2018 position paper by the American Academy of Sleep Medicine 1.
Overview of Cyproheptadine for PTSD Nightmares
The evidence for cyproheptadine in treating PTSD-related nightmares is based on a few small studies with conflicting results. A small case series showed that cyproheptadine eliminated nightmares in three out of four patients with combat-related PTSD, but another case series of 16 patients found no significant change in sleep diary questionnaire items post-treatment 1.
Limitations and Side Effects
The use of cyproheptadine for PTSD nightmares is also limited by its potential side effects, such as fatigue, restlessness, and worsening nightmares, as reported in one of the case series 1.
Alternative Treatments
In contrast, prazosin has been shown to be effective in reducing nightmare frequency and intensity in several studies, including a 15-week randomized controlled trial in active-duty soldiers with combat trauma PTSD 1.
Recommendation
Given the limited and conflicting evidence for cyproheptadine, prazosin is a more established treatment option for PTSD-related nightmares, and should be considered as a first-line treatment, especially in patients who have not responded to other therapies 1. Some key points to consider when prescribing prazosin for PTSD nightmares include:
- Starting with a low dose and gradually increasing as needed and tolerated
- Monitoring for potential side effects, such as dizziness and hypotension
- Using prazosin as part of a comprehensive PTSD treatment plan that includes psychotherapy
- Considering alternative treatments, such as image rehearsal therapy, for patients who do not respond to prazosin or have contraindications to its use 1.
From the Research
Effectiveness of Cyproheptadine for PTSD Nightmares
- Cyproheptadine has been studied as a potential treatment for post-traumatic stress disorder (PTSD) nightmares, with evidence suggesting its efficacy in reducing the frequency and intensity of nightmares 2.
- A retrospective review of nine patients with PTSD found that cyproheptadine treatment resulted in complete remission or a decrease in nightmare intensity and frequency, with a treatment dose of 4 to 12 mg at bedtime 2.
- In a narrative review of pharmacological agents for the treatment of PTSD nightmares, cyproheptadine was listed as one of the agents with evidence of varying quality supporting its use 3.
- However, the review also noted that large randomized controlled trials are needed to evaluate the use of cyproheptadine and other novel agents for PTSD nightmares 3.
Comparison with Other Treatments
- Other pharmacological agents, such as prazosin, doxazosin, and atypical antipsychotics, have also been studied for the treatment of PTSD nightmares, with varying degrees of evidence supporting their efficacy 3, 4, 5.
- Psychotherapy using imagery rehearsal has also been shown to be effective in managing PTSD-related nightmares 6.
- The choice of treatment for PTSD nightmares may depend on individual patient factors, such as the presence of comorbid conditions and the severity of symptoms.