Can Trazodone Cause Nightmares?
Yes, trazodone can paradoxically cause vivid nightmares or worsen existing nightmares in a small subset of patients, though this is uncommon—occurring in approximately 1.4% of users who discontinue the medication for this reason. 1, 2
The Paradox: Treatment vs. Side Effect
Trazodone is primarily used to reduce nightmares, particularly in PTSD patients, where 72% experience beneficial effects with nightmare frequency dropping from 3.3 to 1.3 nights per week. 1, 3 However, the same medication can cause the opposite effect in susceptible individuals:
- In a study of 74 veterans with PTSD, 1 patient (1.4%) discontinued trazodone specifically due to more vivid nightmares, despite the majority experiencing improvement. 1, 2
- This side effect is documented but rare compared to other adverse effects like daytime sedation (60% of tolerators), dizziness, and priapism. 1, 3
FDA-Labeled Adverse Effects
The FDA drug label for trazodone lists "abnormal dreams" as a recognized post-marketing adverse reaction, confirming this phenomenon occurs in clinical practice. 4 While not quantified in frequency, this official recognition validates patient reports of dream-related disturbances.
Clinical Context and Risk Factors
The nightmare side effect appears most problematic during initial treatment:
- Most cases emerge within the first month of therapy. 2
- The effect may be dose-dependent, though specific thresholds are not well-established. 1
- Patients already experiencing nightmares (such as those with PTSD) may be at higher risk for paradoxical worsening. 1, 3
Monitoring Recommendations
The American Academy of Sleep Medicine recommends specific monitoring protocols:
- Assess all patients for changes in dream content or nightmare frequency, particularly during the first month of treatment. 2
- Discontinue trazodone immediately if vivid nightmares develop or pre-existing nightmares worsen. 2
- Direct questioning is essential, as patients may not spontaneously report dream-related side effects. 3
Alternative Approaches
If nightmares occur or worsen on trazodone:
- Prazosin (1-16 mg at bedtime) is the first-line agent for PTSD-related nightmares with Level A evidence, reducing frequency from 4 nights/week to 1-2 nights/week. 5
- Low-dose doxepin may be considered for sleep maintenance without nightmare exacerbation. 2
- Eszopiclone has high-level evidence for PTSD-related insomnia, particularly for sleep maintenance. 5
Common Pitfall to Avoid
Do not assume all sleep-related complaints on trazodone are unrelated to the medication. The drug's reputation as a nightmare-reducing agent can create cognitive bias, leading clinicians to overlook it as a potential cause when patients report worsening dreams. Always consider medication-induced effects when dream disturbances emerge or intensify after starting trazodone. 2, 3
Bottom Line
While trazodone effectively reduces nightmares in most patients (72%), approximately 1-2% experience the opposite effect with more vivid or distressing dreams. 1, 2, 3 This paradoxical reaction warrants immediate discontinuation and consideration of alternative agents like prazosin. 2, 5