Benzodiazepines Are Not Recommended for Nightmares
Benzodiazepines should not be used for the treatment of nightmares, as they have demonstrated no efficacy in controlled trials and carry significant risks of dependence without therapeutic benefit for this indication. 1, 2, 3
Evidence Against Benzodiazepine Use
Clonazepam Shows No Benefit
A randomized, single-blind, placebo-controlled crossover trial in 6 male veterans with combat-related PTSD found no improvement in nightmare frequency (1.42 ± 0.52 vs 1.33 ± 0.45) or intensity (2.15 ± 0.7 vs 2.06 ± 0.6) when comparing clonazepam 2 mg at bedtime to placebo. 1
The American Academy of Sleep Medicine explicitly recommends avoiding benzodiazepines such as clonazepam, which showed no benefit for PTSD nightmares in controlled trials. 2
A 2022 systematic review confirmed that evidence does not support the use of benzodiazepines for post-traumatic nightmares. 3
Dosing Information from Failed Trials
When clonazepam was studied (despite its ineffectiveness), the protocol used:
- 1 mg at bedtime for one week, followed by 2 mg at bedtime for another week 1, 4
- All 6 patients received the final 2 mg dose with no therapeutic benefit 1
Triazolam and Nitrazepam: Limited Evidence
The only benzodiazepines showing any effect on nightmares were studied in a 3-day crossover trial:
- Triazolam 0.5 mg reduced unpleasant dreams from 23 subjects to 2 subjects 1
- Nitrazepam 5 mg reduced unpleasant dreams from 23 subjects to 1 subject 1
- However, this was a very short-term study (3 days) in patients with "disturbed sleep" rather than nightmare disorder, and both drugs were equally effective at reducing unpleasant dreams but not specifically validated for nightmare disorder 1
Critical Pitfalls to Avoid
Risk of Dependence Without Benefit
- Long-term benzodiazepine use results in addiction and physical dependence in some patients, particularly at higher than therapeutic doses 5
- Patients with a history of alcohol or drug abuse pose a higher risk for dependence 5
- The risk-benefit ratio is particularly unfavorable when the medication provides no therapeutic benefit for nightmares 1, 2
Potential for Paradoxical Effects
- One patient in a trazodone study discontinued treatment due to "more vivid nightmares," suggesting that medications affecting sleep architecture, including benzodiazepines like alprazolam, may paradoxically worsen dream content 6
Recommended Alternatives
Instead of benzodiazepines, consider evidence-based alternatives:
First-Line Options
- Prazosin 10-16 mg at bedtime reduces nightmare frequency from approximately 4 nights/week to 1-2 nights/week 2
- Trazodone 100-200 mg (mean effective dose 212 mg/day) reduced nightmare frequency from 3.3 to 1.3 nights/week 1, 2