Medications for Night Terrors
For night terrors specifically, clonazepam is the primary medication option when pharmacotherapy is needed, though behavioral interventions and reassurance are preferred first-line approaches. 1
Critical Distinction: Night Terrors vs. Nightmares
Night terrors and nightmares are fundamentally different conditions requiring different treatments:
- Night terrors occur during deep NREM (stage 3-4) sleep in the first third of the night, with the patient appearing terrified but remaining asleep, showing autonomic hyperactivity (screaming, tachycardia, sweating), and having complete amnesia for the event 1
- Nightmares occur during REM sleep, with full dream recall and awareness upon awakening 2, 3
The evidence you're asking about primarily addresses nightmare disorder, not night terrors. The treatment approaches differ substantially.
Treatment Algorithm for Night Terrors
First-Line: Non-Pharmacological Management
- Reassurance and parental/partner education is the cornerstone of management, as most cases resolve spontaneously 1
- Sleep hygiene optimization is essential since sleep deprivation precipitates night terrors 1
- Anticipatory awakening performed 15-30 minutes before the typical time of night terror episodes is highly effective for frequent events 1
- Environmental safety measures to prevent injury during episodes 1, 4
Pharmacological Treatment (When Necessary)
Clonazepam is the medication of choice when pharmacotherapy is indicated:
- Reserved for frequent, severe episodes causing functional impairment (fatigue, daytime sleepiness, distress) 1
- Used on a short-term basis only at bedtime 1
- Specific dosing not provided in pediatric literature, but adult studies suggest low doses 4, 5
Important caveat: Benzodiazepines carry risks of addiction and relapse of episodes when discontinued, so they should not be first-line treatment 5
Alternative Medications (Limited Evidence)
- SSRIs or tricyclic antidepressants may be selected for patients with high-frequency attacks 5
- Serotonin reuptake inhibitors have been mentioned in adult case reports 4
Critical Clinical Pitfalls
- Do not confuse night terrors with nightmares - the extensive evidence for prazosin, clonidine, and Image Rehearsal Therapy applies to nightmare disorder, not night terrors 2, 3, 6, 7
- Avoid attempting to interrupt or awaken the patient during a night terror episode 1
- Screen for underlying conditions that may precipitate night terrors (sleep apnea, periodic limb movements, medications, stress) and treat these if identified 1
- Most children outgrow night terrors by late adolescence, so aggressive pharmacotherapy is rarely warranted 1
Monitoring Requirements
- Assess for functional impairment (daytime fatigue, sleepiness, distress) to determine if pharmacotherapy is truly needed 1
- Monitor for benzodiazepine dependence if clonazepam is used 5
- Evaluate response to sleep hygiene and anticipatory awakening before escalating to medications 1
When Medical Intervention Is Indicated
Pharmacotherapy should be considered only when: