Can Trazodone Cause Vivid Nightmares?
Yes, trazodone can paradoxically cause vivid nightmares in a small subset of patients, though it is more commonly used to treat nightmares in PTSD patients.
The Paradox: Treatment vs. Side Effect
While trazodone is frequently prescribed off-label to reduce nightmares in PTSD patients, the evidence reveals an important caveat:
- In a retrospective cohort study of 74 veterans with PTSD, 1 patient (approximately 1.4%) discontinued trazodone specifically due to "more vivid nightmares" 1
- This occurred despite 72% of patients experiencing beneficial reduction in nightmare frequency from 3.3 to 1.3 nights per week 1, 2
- The FDA drug label for trazodone lists "abnormal dreams" as a post-marketing adverse reaction, though it does not specify frequency 3
Clinical Context: When Nightmares Occur
The nightmare side effect appears to be:
- Uncommon but documented: Only 1 out of 74 patients in the primary study reported this effect, representing a discontinuation rate of approximately 1.4% for this specific side effect 1
- Unpredictable: There is no clear dose-response relationship identified for this paradoxical effect, as the effective dose range for most patients (50-200 mg) did not predict who would experience worsened nightmares 2
- Part of a broader side effect profile: 19% of patients discontinued trazodone for various side effects, with priapism (5 patients) and daytime sedation (5 patients) being more common reasons than vivid nightmares 1
More Common Side Effects to Monitor
When prescribing trazodone, you should be more concerned about:
- Priapism: Occurred in 12% of patients in one study, requiring direct questioning as patients may not volunteer this information 2
- Daytime sedation and dizziness: The most frequent side effects, affecting 60% of patients who tolerated the medication 1
- Orthostatic hypotension: A significant concern, particularly in elderly patients 1
- Cardiac effects: QT prolongation and arrhythmias have been reported, even at doses of 100 mg/day or less 3
Clinical Recommendation
Monitor all patients starting trazodone for any changes in dream content or nightmare frequency, particularly during the first month of treatment. If vivid nightmares develop or worsen:
- Discontinue trazodone immediately, as symptoms typically resolve within one week of discontinuation 1
- Consider alternative agents such as prazosin (first-line for PTSD-related nightmares) or low-dose doxepin for sleep maintenance 4
- Do not attempt dose reduction, as the paradoxical nightmare effect does not appear to be dose-dependent 2