What is the treatment for night terrors?

Treatment for Night Terrors

Night terrors require reassurance and safety measures as first-line management, with pharmacologic intervention reserved only for severe, frequent cases causing significant functional impairment.

Critical Distinction: Night Terrors vs. Nightmares

Night terrors (sleep terrors) are fundamentally different from nightmares and require different treatment approaches. The evidence provided primarily addresses nightmare disorder, which occurs during REM sleep with dream recall. Night terrors are NREM parasomnias occurring during deep sleep (stage 3-4) with no dream recall and complete amnesia for the event 1.

First-Line Management: Conservative Approach

For typical night terrors, medical intervention is usually unnecessary 1. The cornerstone of management includes:

• Parental education and reassurance that night terrors are benign and self-limited 1
• Safety measures to prevent injury during episodes, including securing the sleep environment 2
• Optimizing sleep hygiene and ensuring adequate sleep duration, as sleep deprivation is a major precipitating factor 1
• Avoiding attempts to interrupt or awaken the child during episodes, as this may prolong the event 1

Behavioral Interventions for Frequent Episodes

Anticipatory awakening is the most effective behavioral technique when episodes occur predictably 1:

• Wake the child approximately 30 minutes before the typical time of the sleep terror
• Keep the child awake for 5 minutes, then allow return to sleep
• This disrupts the deep sleep cycle that triggers the episodes 1

Hypnosis has demonstrated effectiveness in case studies, using techniques focused on regulating sleep cycles and preventing rapid descent into extremely deep sleep stages 3.

Autogenic training (a relaxation technique) successfully eliminated persistent night terrors in documented cases 4.

Pharmacologic Treatment: Reserved for Severe Cases

Medications should be considered only when episodes are frequent, severe, or cause significant functional impairment (fatigue, daytime sleepiness, distress) 1.

Recommended Medications:

• Clonazepam is the primary pharmacologic option for severe, frequent night terrors, used on a short-term basis at bedtime 1

  • Note: While clonazepam is not recommended for nightmare disorder 5, it has documented efficacy for night terrors specifically 1

• Selective serotonin reuptake inhibitors (SSRIs) such as paroxetine have shown success in treatment-resistant cases with long-standing histories 6, 2

• Benzodiazepines (general class) may be used for adults with severe episodes 2

Clinical Algorithm

1. Initial presentation: Confirm diagnosis (NREM parasomnia with amnesia, autonomic hyperactivity, occurring in first third of night) 1

2. Identify and address precipitating factors: Sleep deprivation, stress, fever, medications, sleep-disordered breathing 1

3. Implement conservative measures: Safety precautions, sleep hygiene optimization, parental education 2, 1

4. For frequent predictable episodes: Trial of anticipatory awakening 1

5. For persistent severe cases: Consider short-term clonazepam or behavioral therapy (hypnosis, autogenic training) 3, 1, 4

6. For treatment-resistant cases: Consider SSRI therapy 6, 2

Important Caveats

• Most children outgrow night terrors by late adolescence without any intervention 1
• The constitutional/genetic basis is well-established, though expression may be influenced by stress and life circumstances 2
• Episodes typically occur 1-3 hours after sleep onset during arousal from deep NREM sleep 1
• Prevalence is 1-6.5% in children aged 1-12 years, peaking at ages 5-7 1
• Do not confuse with nightmare disorder, which requires entirely different treatment (Image Rehearsal Therapy) 7, 8, 9