Medication for Nightmares

First-Line Approach

The American Academy of Sleep Medicine recommends Image Rehearsal Therapy as the primary treatment for nightmare disorder, achieving a 60-72% reduction in nightmare frequency 1
Prazosin is the most established medication option for patients requiring pharmacological intervention, according to the American Academy of Sleep Medicine 2, 3

The American Academy of Sleep Medicine suggests starting prazosin at 1 mg at bedtime and titrating by 1-2 mg every few days until nightmares are controlled or side effects emerge, with a maximum recommended dose of 20 mg at bedtime 2, 1
The average effective dose is approximately 3 mg for civilians, though military veterans with combat-related PTSD often require higher doses, with a range of 9.5-13.3 mg/day 2
The American Academy of Sleep Medicine initially gave prazosin Level A evidence based on three randomized controlled trials showing significant reduction in PTSD-associated nightmares, but this was later downgraded due to conflicting evidence 2, 3

Topiramate is a second-line option for PTSD nightmares, with a starting dose of 12.5-25 mg daily and an effective dose of ≤100 mg/day for 91% of responders, achieving a 79% reduction in nightmares 4
Trazodone is considered for comorbid insomnia, with a dose range of 25-600 mg at bedtime, reducing nightmare frequency from 3.3 to 1.3 nights per week in 72% of veterans 6, 5
Nabilone, a synthetic cannabinoid, starts at 0.5 mg and titrates to a maximum of 3 mg, reducing CAPS nightmare scores by 3.6 points versus 1.0 for placebo in military personnel 7

Night terrors occur during deep non-REM sleep with complete amnesia, while nightmares occur during REM sleep with full recall, according to the American Academy of Sleep Medicine 8
Prazosin has no role in night terrors, and clonazepam is considered only when episodes are frequent, severe, or causing functional impairment 8

The American Academy of Sleep Medicine recommends initiating Image Rehearsal Therapy for all patients with nightmare disorder, and starting prazosin 1 mg at bedtime for PTSD-associated nightmares, with monitoring of blood pressure and consideration of SSRI interactions 1, 2, 3
If prazosin fails or is not tolerated, consider topiramate, trazodone, or nabilone, depending on patient-specific factors and comorbidities 4, 6, 7

The American Academy of Sleep Medicine warns against confusing night terrors with nightmares, as treatments differ completely, and against ignoring SSRI interactions with prazosin, which may significantly reduce efficacy 8, 3
The American Academy of Sleep Medicine also advises against using nefazodone as first-line due to hepatotoxicity risk, and against prescribing prazosin without blood pressure monitoring due to the risk of orthostatic hypotension 6, 2, 1