What are alternative treatments for night terrors since prazosin (generic name: prazosin) is causing excessive daytime tiredness?

Alternative Treatments for Night Terrors When Prazosin Causes Excessive Daytime Tiredness

Since prazosin is causing intolerable daytime fatigue, you should first try Image Rehearsal Therapy (IRT), which is now the first-line recommended treatment for trauma-related nightmares, or consider switching to an alternative medication such as clonidine or doxazosin. 1

First-Line Non-Pharmacological Option

Image Rehearsal Therapy (IRT) should be your initial alternative approach, as it is now recommended as first-line treatment by the American Academy of Sleep Medicine for PTSD-associated nightmares. 1

• IRT involves altering nightmare content by creating positive images and rehearsing the rewritten dream scenario for 10-20 minutes daily. 1
• This behavioral therapy can be used alone or combined with cognitive behavioral therapy, exposure therapy, relaxation techniques, and eye movement desensitization and reprocessing. 1
• IRT shows small to moderate effects on nightmare frequency (effect size 0.51) and sleep quality (effect size 0.51), with benefits that may be more sustainable long-term than medication alone. 2
• Combining IRT with cognitive behavioral therapy for insomnia (CBT-I) may lead to improved outcomes. 3

Alternative Medication Options

Clonidine (Level C Recommendation)

Clonidine may be considered as an alternative alpha-adrenergic agent if you prefer to continue pharmacological treatment. 4

• Clonidine is an α2-adrenergic receptor agonist that suppresses sympathetic nervous system outflow throughout the brain, similar to prazosin's mechanism. 4
• Dosing ranges from 0.2 to 0.6 mg in divided doses, which reduced nightmares in 11/13 patients in case series. 4
• Important caveat: Clonidine shares prazosin's potential for postural hypotension and may also cause sedation, though individual responses vary. 4
• The evidence base is weaker than for prazosin (no randomized controlled trials), but it has been used as "a mainstay of PTSD treatment for severely traumatized refugees for over 20 years." 4

Doxazosin (Emerging Alternative)

Doxazosin is a longer-acting α-1-adrenergic antagonist that may have fewer side effects than prazosin. 5

• Doxazosin has a longer half-life than prazosin, which may reduce the daytime fatigue you're experiencing. 5
• In a chart review of 51 patients with PTSD and/or borderline personality disorder, 25% achieved full remission of nightmares over 12 weeks. 5
• Sleep recuperation improved within the first 4 weeks of treatment. 5
• This option requires discussion with your prescriber, as it's being used based on emerging evidence rather than large randomized trials. 5

Other Medications (Lower Quality Evidence)

If the above options fail, several other medications may be considered, though the data is sparse and side effects can be significant: 4

• Trazodone (25-600 mg, mean 212 mg): 72% of veterans found it decreased nightmares, but 60% experienced side effects including daytime sedation, dizziness, headache, priapism, and orthostatic hypotension. 4
• Atypical antipsychotics (olanzapine, risperidone, aripiprazole): May be considered for treatment-resistant cases. 4
• Topiramate, gabapentin, low-dose cortisol (10 mg/day): Limited evidence but may be options. 4

Important Clinical Considerations

Why Prazosin May Be Causing Your Symptoms

• Your excessive tiredness could be related to prazosin's blood pressure-lowering effects causing orthostatic symptoms throughout the day. 6
• Check if you're taking SSRIs concurrently, as they may diminish prazosin's response and could be contributing to your ongoing symptoms. 7, 8
• The persistence of night terrors despite prazosin suggests either inadequate dosing, developing tolerance, or that prazosin isn't the right medication for you. 7

Monitoring and Safety

• If you switch to clonidine or doxazosin, blood pressure monitoring remains essential, particularly after initial dosing and dose increases. 1
• Do not abruptly stop prazosin without medical supervision, as nightmares may return to baseline intensity. 8, 1
• Dizziness, lightheadedness, or fainting may occur with any alpha-blocker, especially when rising from lying or sitting positions. 6

Recommended Action Plan

1. Discuss starting Image Rehearsal Therapy with a therapist trained in trauma-focused treatments while continuing or tapering prazosin. 1
2. If medication is still needed, ask your prescriber about switching to doxazosin (longer half-life, potentially fewer daytime effects) or clonidine. 5, 4
3. Review all current medications with your prescriber, particularly SSRIs, which may be interfering with treatment response. 7
4. Consider combination therapy of IRT plus medication for potentially better long-term outcomes. 3