What is the recommended treatment for a patient experiencing night terrors?

Treatment of Night Terrors

Reassure the patient and family that night terrors are benign NREM sleep parasomnias requiring primarily safety measures and sleep hygiene optimization, with clonazepam reserved only for severe, persistent cases causing functional impairment. 1

Critical First Step: Confirm the Diagnosis

Night terrors are fundamentally different from nightmares and require completely different management:

• Night terrors occur during NREM slow-wave sleep in the first third of the night, characterized by confusion, screaming, autonomic hyperactivity (tachycardia, diaphoresis, dilated pupils), and complete amnesia for the event the next morning 1, 2
• Nightmares occur during REM sleep, are recalled upon awakening, and respond to imagery rehearsal therapy—treatments that are inappropriate and ineffective for night terrors 1
• The patient is difficult to arouse during episodes, appears terrified with a frightened expression, and typically settles back to sleep without fully awakening 2

First-Line Management: Safety and Sleep Hygiene

Environmental Safety Modifications

• Remove all dangerous objects from the bedroom (sharp items, furniture with hard edges) and consider installing door alarms if the patient wanders during episodes to prevent injury 1, 3
• Ensure windows are secured and consider moving the patient to a ground-floor bedroom if feasible 1

Sleep Hygiene Optimization

• Establish a consistent sleep-wake schedule with adequate total sleep duration, as sleep deprivation is a major precipitant of night terrors 1, 2
• Avoid sleep-fragmenting substances including caffeine and excessive screen time before bed 1
• Screen for and treat underlying sleep disorders that fragment slow-wave sleep, particularly obstructive sleep apnea, as arousals from deep sleep trigger night terror episodes 1, 2

Avoid Interrupting Episodes

• Do not attempt to awaken or console the patient during an episode, as this may prolong the event or cause agitation 2
• Simply ensure safety and allow the episode to resolve naturally 2

Pharmacological Treatment: Reserved for Severe Cases Only

When to Consider Medication

Pharmacological intervention is indicated only when night terrors are frequent, severe, or cause functional impairment such as daytime fatigue, sleepiness, or significant distress to the patient or household 2, 4

Medication of Choice

• Clonazepam at bedtime is the medication of choice for severe, persistent night terrors, with use limited to 3-6 weeks to avoid dependence risk 1, 3
• Benzodiazepines suppress slow-wave sleep arousals and have demonstrated efficacy in eliminating night terror episodes 4
• Midazolam has shown efficacy in eliminating night terrors in all but one patient in a controlled study, with favorable modification of sleep architecture 5

Medications to Avoid

• Do not use prazosin or clonidine—these are indicated for nightmares (not night terrors) and cause problematic orthostatic hypotension and blood pressure effects 1, 6
• These medications target REM sleep phenomena and are ineffective for NREM parasomnias 6

Alternative Non-Pharmacological Interventions

Anticipatory Awakening

• Wake the patient approximately 30 minutes before the typical time of night terror occurrence (usually within the first 2-3 hours of sleep) 2
• This technique is often effective for frequently occurring night terrors by disrupting the arousal pattern from slow-wave sleep 2

Hypnosis

• Hypnotic techniques focusing on gradual sleep onset and regular cycling through sleep stages may be considered, with one case report showing complete resolution maintained for 2 years 7
• Suggestions should emphasize not dropping too quickly into extremely deep stages of sleep 7

Follow-Up and Referral

• Reassess within 4-6 weeks to evaluate episode frequency, effectiveness of interventions, and impact on quality of life 1, 3
• Refer to a sleep specialist if: night terrors persist despite conservative management, worsen over time, continue beyond adolescence in younger patients, or if other sleep disorders (sleep apnea, seizures) are suspected 1, 3
• Most patients outgrow night terrors by late adolescence, with 50% stopping by age 8 years in pediatric cases 8

Common Pitfalls to Avoid

• Do not confuse night terrors with nightmares—applying nightmare treatment protocols (imagery rehearsal therapy, systematic desensitization) to night terrors is ineffective and wastes resources 1
• Do not use long-term benzodiazepines—limit to 3-6 weeks maximum due to dependence risk 1, 3
• Do not overlook underlying sleep apnea—this is a common treatable trigger that fragments slow-wave sleep 1, 2
• Do not prescribe prazosin thinking it will help—this is a common error based on confusion with nightmare treatment 1, 6