From the Guidelines
Cyproheptadine should be used off-label for nightmares at a typical starting dose of 4 mg taken 1-2 hours before bedtime, as recommended by the American Academy of Sleep Medicine position paper 1. The dose may be gradually increased if needed, with most adults tolerating 8-16 mg per night, though some may require up to 24 mg for effectiveness, as seen in a case series of four veterans with combat-related PTSD 1.
Key Considerations
- Treatment duration varies by individual response, but reassessment after 4-8 weeks is reasonable.
- Cyproheptadine works by blocking histamine H1 receptors and serotonin receptors, which helps regulate sleep architecture and may reduce REM sleep when nightmares often occur.
- Common side effects include drowsiness, dry mouth, increased appetite, and weight gain.
- This medication should be used cautiously in patients with glaucoma, urinary retention, cardiovascular disease, or those taking other sedating medications.
- Abrupt discontinuation should be avoided; tapering is recommended after extended use.
Alternative Therapies
- Image rehearsal therapy is recommended for the treatment of PTSD-associated nightmares and nightmare disorder 1.
- Other therapies that may be used for the treatment of PTSD-associated nightmares include cognitive behavioral therapy, cognitive behavioral therapy for insomnia, and exposure, relaxation, and rescripting therapy 1.
- If nightmares persist despite treatment, further evaluation for underlying conditions like PTSD or other sleep disorders may be necessary.
From the FDA Drug Label
DOSAGE AND ADMINISTRATION DOSAGE SHOULD BE INDIVIDUALIZED ACCORDING TO THE NEEDS AND THE RESPONSE OF THE PATIENT. The therapeutic range is 4 mg to 20 mg a day, with the majority of patients requiring 12 mg to 16 mg a day. An occasional patient may require as much as 32 mg a day for adequate relief. It is suggested that dosage be initiated with 4 mg (1 tablet) three times a day and adjusted according to the size and response of the patient.
The FDA drug label does not answer the question.
From the Research
Cyproheptadine Dosing for Nightmares
- The dosing of cyproheptadine for nightmares associated with posttraumatic stress disorder (PTSD) has been studied in a retrospective review, which found that a treatment dose of 4 to 12 mg at bedtime was effective in relieving nightmares 2.
- However, there is limited information available on the specific dosing of cyproheptadine for nightmares, and more research is needed to determine the optimal dose and treatment regimen.
- Other studies have investigated the use of various pharmacological agents, including prazosin, doxazosin, clonidine, and tricyclic antidepressants, for the treatment of PTSD-related nightmares 3, 4, 5, 6.
- These studies suggest that several agents may be effective in reducing the frequency and intensity of nightmares, but the evidence is not yet conclusive, and further research is needed to determine the most effective treatments.