Can Trazodone Cause Nightmares?
Yes, trazodone can paradoxically cause or worsen nightmares in a small subset of patients, though it is more commonly used to treat nightmares, particularly in PTSD. Approximately 1.4% of patients discontinued trazodone specifically due to more vivid nightmares in clinical studies, despite the majority experiencing nightmare reduction 1, 2.
The Paradox: Treatment vs. Side Effect
Primary Use for Nightmare Reduction
- Trazodone is considered a second-line treatment for PTSD-associated nightmares by the American Academy of Sleep Medicine, with 72% of patients experiencing significant benefit—reducing nightmare frequency from 3.3 nights per week to 1.3 nights per week (p < 0.005) 1, 3.
- The effective dose range for nightmare reduction is typically 50-200 mg nightly for 70% of patients, with a mean effective dose of 212 mg 1, 3.
Paradoxical Nightmare Worsening
- In a study of 74 veterans with PTSD, 1 patient (1.4%) discontinued trazodone specifically because of more vivid nightmares, making this a documented but uncommon adverse effect 1, 2.
- The FDA label for trazodone lists "abnormal dreams" as a post-marketing adverse reaction, though nightmares are not explicitly mentioned in controlled trial data 4.
Clinical Decision-Making Algorithm
When to Use Trazodone for Nightmares
- Consider trazodone 50-100 mg at bedtime as second-line therapy when prazosin (first-line) is ineffective, not tolerated, or contraindicated for PTSD-related nightmares 5, 6.
- Start at 25-50 mg and titrate to 100-200 mg based on response and tolerability 5, 6.
Monitoring for Nightmare Worsening
- Monitor all patients during the first month of treatment for any changes in dream content or worsening nightmare frequency 2.
- If vivid nightmares develop or worsen, discontinue trazodone immediately and consider alternative agents such as prazosin (10-16 mg at bedtime) or topiramate 2, 6.
More Common Side Effects to Anticipate
The following side effects are far more common than nightmare worsening and should be the primary monitoring focus:
- Daytime sedation and dizziness affect 60% of patients who tolerate the medication 1.
- Priapism occurred in 12% of patients in one study—a higher rate than expected—warranting direct questioning about this side effect at each visit 3.
- Orthostatic hypotension is particularly concerning in elderly patients and those with cardiovascular disease 1, 4, 7.
- Overall discontinuation rate for any side effect was 19%, with priapism and daytime sedation being more common reasons than vivid nightmares 1.
Critical Clinical Caveats
- The nightmare-worsening effect appears idiosyncratic and unpredictable, occurring in a very small minority despite the drug's overall benefit for nightmare reduction 1, 2.
- Most patients in the studies were on concurrent psychotropic medications (antidepressants, antipsychotics, pain medications), which may influence individual response 1.
- If nightmares worsen on trazodone, this represents a treatment failure requiring immediate medication change, not dose adjustment 2.