What are the treatments for patients (pts) with nightmares?

From the Guidelines

Treatments for post-traumatic nightmares should prioritize image rehearsal therapy (IRT) as the first-line treatment, as it has been shown to be effective in reducing nightmare frequency and improving sleep quality, as recommended by the American Academy of Sleep Medicine position paper 1.

Key Treatment Options

• Image rehearsal therapy (IRT): patients rewrite their nightmare narrative while awake and mentally rehearse the new script daily for 10-20 minutes
• Cognitive behavioral therapy for insomnia (CBT-I) and exposure therapy: can also be effective in reducing nightmares and improving sleep quality
• Medications: prazosin is most studied, typically starting at 1mg at bedtime and gradually increasing to 3-15mg as needed
• Other medication options: trazodone (50-200mg), clonidine (0.1-0.3mg), or low-dose doxepin (3-6mg) at bedtime

Important Considerations

• Benzodiazepines and antipsychotics should be avoided for long-term use due to side effects and dependency concerns
• Treatment should be individualized based on comorbidities, with nightmares often improving as underlying PTSD or trauma symptoms resolve
• Sleep hygiene measures like maintaining regular sleep schedules, avoiding caffeine and alcohol before bed, and creating a comfortable sleep environment can support these treatments
• Patients should be monitored for medication side effects and treatment response, with adjustments made as needed, as recommended by the American Academy of Sleep Medicine position paper 1

Supporting Evidence

• A systematic review of the literature on nightmare disorder treatment options, including IRT and medications, has been conducted by the American Academy of Sleep Medicine 1
• The effectiveness of IRT in reducing nightmare frequency and improving sleep quality has been demonstrated in several studies, including a Level 1 study with 168 women with moderate-to-severe PTSD symptoms 1

From the Research

Treatments for Post-Traumatic Nightmares

• Various pharmacological agents have been studied for the treatment of post-traumatic nightmares, including prazosin, doxazosin, clonidine, tricyclic antidepressants, and atypical antipsychotics 2, 3.
• Prazosin has been consistently reported to reduce nightmare severity in open-label trials, retrospective chart reviews, and single case reports, although results from randomized controlled trials are mixed 2.
• Other agents such as gabapentin, topiramate, and cyproheptadine have also shown promise in reducing nightmares, while evidence does not support the use of venlafaxine, β-blockers, benzodiazepines, or sedative hypnotics 3.
• Novel agents like ramelteon, cannabinoids, ketamine, and psychedelic agents have shown promising results, but large randomized controlled trials are needed to evaluate their efficacy 3.

Non-Pharmacological Interventions

• Imagery rescripting therapy (IRT) and exposure, relaxation, and rescripting therapy (ERRT) are preferred non-pharmacological treatments for post-traumatic nightmares 4.
• Combining cognitive behavior therapy for insomnia (CBT-I) with IRT or ERRT may lead to improved outcomes 4.
• Virtual technology and inpatient settings have also been explored as potential platforms for delivering non-pharmacological interventions for post-traumatic nightmares 4.

Clinical Practice and Guidelines

• A survey of psychiatrists found that prazosin is frequently prescribed off-label for post-traumatic stress disorder-associated nightmares, despite conflicting published evidence and a lack of local guideline recommendations 5.
• The American Academy of Sleep Medicine and the Veterans Health Administration/Department of Defense have downgraded prazosin as a first-line pharmacological intervention for post-traumatic nightmares 4.
• Clonidine has been studied as a potential treatment for post-traumatic stress disorder, particularly for sleep and nightmares, but more research is needed to establish its efficacy 6.