Management of Nightmare Disorder in Adults

Erin D. Callen, PharmD, BCPS; Tiffany L. Kessler, PharmD, BCPS; Krista G. Brooks, PharmD; Tom W. Davis, MD


US Pharmacist. 2018;43(11):21-26. 

In This Article

Pharmacologic Treatment

Although no pharmacologic agent is recommended in the position paper, many of the medications discussed are designated may be used.[3]Table 2 provides a detailed summary of these agents, along with available trial data. Prazosin remains the drug of choice and is the only one indicated for both nightmare types.[3] Therefore, prazosin will be discussed first, followed by the remaining agents and drug classes in alphabetical order.

Prazosin: The 2010 AASM best-practice guide recommended prazosin for nightmare disorder; however, the current position paper has downgraded its classification to may be used based on a recent publication that did not find a statistical difference versus placebo.[3,5] This trial had the largest patient population to date and was the first to show a lack of benefit with prazosin; however, the majority of patients in both groups were concurrently receiving an antidepressant.[5–16] This is important because a prior trial noted a decreased response to prazosin in patients concurrently taking a selective serotonin reuptake inhibitor (SSRI).[7] Further clarification of this possible interaction is needed.

Atypical Antipsychotics: In small studies, aripiprazole, olanzapine, and risperidone have been evaluated as adjunctive treatments for PTSD, and all of these agents have demonstrated some benefit for the associated nightmares. These medications, however, are limited by their adverse-effect profile.[17–20]

Benzodiazepines: Nitrazepam and triazolam were assessed in a single 3-day trial in which patients with disturbed sleep (nightmare type was not identified) reported a decrease in "unpleasant dreams."[21] Patients took just one dose of each medication, followed by a 1-day washout period. Clonazepam is currently not recommended because it was found to be ineffective for PTSD-associated nightmares in a randomized clinical trial.[22]

Clonidine: The two studies of clonidine conducted in PTSD patients had positive results; however, there were only 13 participants.[23,24]

Cyproheptadine: Three small trials of cyproheptadine in PTSD patients had conflicting data. Adverse effects may outweigh the benefit.[25–27]

Gabapentin: A single retrospective study of gabapentin in patients with PTSD showed a marked or moderate improvement in sleep, as well as a decreased frequency or intensity of nightmares.[28]

Nabilone: In a single open-label study, the majority of PTSD patients receiving nabilone experienced cessation of nightmares or a significant reduction in nightmare intensity. A smaller randomized trial also found a decreased incidence of PTSD-related nightmares.[29,30]

Phenelzine: Two studies of phenelzine in PTSD patients indicated a benefit. However, all patients in the larger study ultimately withdrew because the improvement in nightmare severity was negligible, was short-lived, or plateaued.[31,32]

SSRIs and Serotonin-Norepinephrine Reuptake Inhibitors: Of these agents, only fluvoxamine is designated may be used. Two small clinical studies of fluvoxamine showed benefit; however, in one study, many patients withdrew because of side effects.[3,33,34] Venlafaxine has shown benefit for general PTSD symptoms, but not nightmares; therefore, it is not recommended.[1,3]

Topiramate: Despite positive results in several studies of PTSD-associated nightmares, topiramate use may be limited because of adverse effects.[3,35–38]

Trazodone: The only study to evaluate trazodone found it to be effective, but 19% of patients were unable to maintain an effective dose, and many experienced at least one side effect.[39]

Tricyclic Antidepressants (TCAs): One small case series in patients with PTSD suggested beneficial effects; however, findings were limited because TCA treatment was varied.[40]