What are the management options for nightmare disorder?

From the Guidelines

To manage nightmares effectively, imagery rehearsal therapy (IRT) is the most recommended approach, as it has been shown to significantly reduce nightmare frequency and improve sleep quality, according to the most recent and highest quality study 1.

Key Recommendations

• Establish a consistent sleep schedule and create a relaxing bedtime routine to promote better sleep.
• Practice stress reduction techniques such as meditation, deep breathing, or progressive muscle relaxation before bed to reduce anxiety.
• Use IRT by rewriting the nightmare with a positive ending while awake and mentally rehearsing this new version daily, as recommended by the American Academy of Sleep Medicine 1.
• Avoid alcohol, caffeine, and screen time before bed as these can worsen sleep quality and trigger nightmares.
• Keep the bedroom cool, dark, and quiet to promote better sleep.

Medications and Therapies

• For persistent nightmares, medications like prazosin (starting at 1mg at bedtime, gradually increasing to 3-15mg as needed) may help, especially for trauma-related nightmares, as recommended by the American Academy of Sleep Medicine 1.
• Cognitive behavioral therapy for insomnia (CBT-I) can address underlying sleep issues and reduce nightmare frequency.
• Other therapies such as cognitive behavioral therapy, exposure, relaxation, and rescripting therapy, and eye movement desensitization and reprocessing may also be effective in managing nightmares, as suggested by the American Academy of Sleep Medicine 1.

Important Considerations

• The ultimate judgment regarding the propriety of any specific care must be made by the clinician, in light of the individual circumstances presented by the patient, accessible treatment options, and resources, as stated by the American Academy of Sleep Medicine 1.
• If nightmares persist or significantly impact daily functioning, consult a healthcare provider for personalized treatment.

From the Research

Nightmare Management Treatments

• Pharmacological treatments:
  • Prazosin: an alpha blocker that has been shown to be effective in reducing nightmare frequency, posttraumatic stress symptoms, and improving sleep quality 2, 3, 4, 5
  • Nabilone: a synthetic cannabinoid that appears to be promising in the treatment of post-traumatic nightmares 3
• Non-pharmacological treatments:
  • Imagery Rehearsal Therapy (IRT): a psychological treatment that has been shown to be effective in reducing nightmare frequency, posttraumatic stress symptoms, and improving sleep quality 2, 6, 4, 5
  • Exposure, Relaxation, and Rescripting Therapy (ERRT): a psychological treatment that has been shown to be effective in reducing nightmare frequency and improving sleep quality, particularly in children and individuals with comorbid bipolar disorder and post-traumatic nightmares 3
  • Cognitive Behavior Therapy for Insomnia (CBT-I): a psychological treatment that can be combined with IRT or ERRT to improve sleep quality and reduce posttraumatic stress symptoms 3, 5

Effectiveness of Treatments

• Prazosin and IRT have been shown to be equally effective in reducing nightmare frequency, posttraumatic stress symptoms, and improving sleep quality 2, 5
• Combining CBT-I with IRT may lead to improved outcomes in terms of sleep quality and posttraumatic stress symptoms 3, 5
• ERRT has been shown to be effective in reducing nightmare frequency and improving sleep quality in children and individuals with comorbid bipolar disorder and post-traumatic nightmares 3

Recommendations

• The American Academy of Sleep Medicine task force recommends IRT as the first-line treatment for trauma-related nightmares, while prazosin may be used as an alternative 2, 3
• The Veterans Health Administration/Department of Defense recommends IRT and ERRT as preferred non-pharmacological treatments for post-traumatic nightmares, while prazosin is no longer considered a first-line pharmacological intervention 3