How to manage night terrors in a patient with bipolar disorder taking Lamotrigine (lamotrigine)?

Managing Night Terrors in Bipolar Disorder Patients on Lamotrigine

Critical First Step: Confirm the Diagnosis

You must first determine whether this patient has true night terrors (NREM parasomnia) or nightmares (REM parasomnia), as the treatment approaches are fundamentally different. 1

Distinguishing Features to Assess:

• Night terrors occur in the first third of the night during slow-wave sleep, with confusion, screaming, autonomic hyperactivity (tachycardia, sweating), and complete amnesia for the event 1
• Nightmares occur during REM sleep (later in the night), involve dysphoric dreams that are well-remembered, with rapid orientation upon awakening 2

If True Night Terrors (NREM Parasomnia)

Non-Pharmacological Management (First-Line)

For night terrors, behavioral interventions should be attempted first, as the pharmacological evidence base specifically addresses nightmares, not night terrors. 1

• Ensure sleep hygiene optimization: consistent sleep schedule, adequate sleep duration, avoid sleep deprivation 1
• Address potential triggers: stress reduction, avoid alcohol and sedating medications that fragment sleep 1
• Safety measures: remove dangerous objects from bedroom, consider door alarms 1

Pharmacological Considerations

Avoid prazosin and clonidine in patients with any blood pressure concerns, as both cause orthostatic hypotension. 3, 1 This is particularly relevant since these are first-line agents for nightmares but contraindicated for blood pressure issues.

Continue lamotrigine as prescribed for bipolar disorder, as it does not worsen parasomnias and is well-tolerated with common side effects being headache, nausea, and insomnia—not night terrors 4, 5, 6

If Nightmares (REM Parasomnia)

First-Line Treatment: Image Rehearsal Therapy

Image Rehearsal Therapy (IRT) is the recommended first-line treatment for nightmare disorder with Level A evidence. 2, 3

• IRT involves recalling the nightmare, writing it down, changing the content to a more positive scenario, and rehearsing the rewritten dream for 10-20 minutes daily while awake 2
• This cognitive behavioral technique is effective for both PTSD-associated and idiopathic nightmares 2

Pharmacological Options for Nightmares

If behavioral therapy fails or nightmares are severe, prazosin is the first-line pharmacotherapy with Level A evidence. 3

Prazosin Protocol:

• Start at 1 mg at bedtime, increase by 1-2 mg every few days to average effective dose of 3 mg 3
• Monitor blood pressure closely due to orthostatic hypotension risk 3
• Three Level 1 studies demonstrated significant reduction in trauma-related nightmares 3

Alternative Pharmacological Options (if prazosin contraindicated or ineffective):

Topiramate may be considered as second-line:

• Start 25 mg/day, titrate to effect or maximum 400 mg/day 2, 3
• Reduced nightmares in 79% of patients with full suppression in 50% 2, 3
• Side effects include cognitive impairment, paresthesias, and weight loss 2

Trazodone is another option:

• Mean effective dose 212 mg/day 2, 3
• Reduced nightmare frequency from 3.3 to 1.3 nights/week 2, 3
• Common side effects: daytime sedation (60%), dizziness, priapism (rare but serious) 2

Atypical antipsychotics (risperidone, olanzapine, aripiprazole):

• Risperidone 1-3 mg/day showed moderate-to-high efficacy 2, 3
• Consider if patient has comorbid psychotic features 2

Medications to Avoid

Do not use clonazepam—it is ineffective for nightmare disorder with no improvement over placebo 2, 3

Do not use venlafaxine—it shows no significant benefit over placebo for distressing dreams 2, 3

Lamotrigine Considerations

Continue lamotrigine for bipolar disorder maintenance, as it is effective for preventing depressive episodes and does not cause or worsen sleep parasomnias 4, 5, 6, 7

• Lamotrigine's common side effects (headache, nausea, insomnia) do not include night terrors or nightmares 4, 5, 6
• If adding medications for nightmares, no dose adjustment of lamotrigine is needed unless adding valproate or carbamazepine 4, 5

Clinical Pitfalls to Avoid

• Do not assume all nocturnal disturbances are nightmares—night terrors require different management 1
• Do not start prazosin without blood pressure monitoring—orthostatic hypotension is the primary concern 3
• Do not discontinue lamotrigine—it is not causing the parasomnia and is essential for bipolar disorder maintenance 4, 6, 7
• Do not use benzodiazepines long-term—clonazepam is ineffective and other benzodiazepines lack evidence 2