Medication for Night Terrors
Critical Distinction: Night Terrors vs. Nightmares
Night terrors and nightmares are fundamentally different conditions requiring different treatments. Night terrors are non-REM parasomnias occurring in the first third of sleep with autonomic hyperactivity and amnesia, while nightmares are REM-related dream disturbances with recall 1, 2. The evidence you're asking about primarily addresses nightmare disorder, not night terrors.
Treatment for True Night Terrors (Parasomnias)
First-Line Approach
- Reassurance and sleep hygiene are the primary interventions for night terrors, as most children outgrow this benign condition by late adolescence 1.
- Ensure adequate sleep duration, as sleep deprivation is a major precipitating factor for night terrors 1.
- Anticipatory awakening 15-30 minutes before the typical time of night terror episodes is often effective for frequent occurrences 1.
Pharmacological Options (When Non-Pharmacological Fails)
- Clonazepam may be considered on a short-term basis at bedtime if night terrors are frequent, severe, or cause functional impairment such as fatigue and daytime sleepiness 1.
- Benzodiazepines should not be first-line due to addiction potential and relapse of episodes upon discontinuation 3.
- SSRIs or tricyclic antidepressants can be selected for patients with high-frequency attacks 3.
- In adults, treatment may include benzodiazepines and serotonin reuptake inhibitors, particularly when related to stressful life events 4.
Important Caveats
- Do not attempt to interrupt a sleep terror episode, as this is ineffective and may worsen agitation 1.
- Medical intervention is usually unnecessary; most cases require only parental education 1.
- Underlying medical conditions should be treated if identified as precipitating factors 1.
If You Actually Mean Nightmare Disorder
First-Line Treatment
- Image Rehearsal Therapy (IRT) is the recommended first-line treatment for nightmare disorder, showing 60-72% reduction in nightmare frequency 5, 6.
- IRT involves recalling the nightmare, rewriting it with positive elements, and rehearsing the new scenario for 10-20 minutes daily 5, 6.
Pharmacological Options for Nightmares
PTSD-Associated Nightmares:
- Prazosin is the most established medication with Level A evidence, starting at 1 mg at bedtime and titrating by 1-2 mg every few days 5, 6, 7.
- Clonidine (0.2-0.6 mg divided doses) is the primary alternative with Level C evidence 5, 6, 8.
- Other options include trazodone (mean dose 212 mg), atypical antipsychotics (olanzapine, risperidone, aripiprazole), topiramate, cyproheptadine, fluvoxamine, gabapentin, and phenelzine 5, 7.
Non-PTSD Nightmare Disorder:
- Prazosin, nitrazepam, and triazolam may be used 5.
- Clonazepam and venlafaxine are specifically NOT recommended, as they show no benefit over placebo 5, 6, 7.