First-Line Treatments

The American Academy of Sleep Medicine recommends Image Rehearsal Therapy (IRT) as the first-line treatment for PTSD-associated nightmares, which involves altering nightmare content by creating positive images and rehearsing the rewritten dream scenario for 10-20 minutes daily 1, 2
IRT is a behavioral therapy that may be used in conjunction with other therapies such as cognitive behavioral therapy, exposure therapy, relaxation techniques, and eye movement desensitization and reprocessing 2

Pharmacological Options

The American Academy of Sleep Medicine suggests that Prazosin, an alpha-1 adrenergic receptor antagonist, is the most established medication for PTSD-related nightmares, with a starting dose of 1 mg at bedtime, gradually increasing by 1-2 mg every few days until clinical response 3, 4, 5
Effective doses of Prazosin range from 3-4 mg/day for civilians to 9.5-15.6 mg/day for military veterans, and it works by reducing CNS sympathetic outflow throughout the brain, targeting mechanisms implicated in nightmare pathogenesis 3, 4, 5

The American Academy of Sleep Medicine recommends monitoring blood pressure when using either Prazosin or Propranolol due to potential hypotensive effects, and notes that discontinuation of medications may lead to a return of nightmares to baseline intensity 4, 5

The American Academy of Sleep Medicine suggests that other medications that may be considered for PTSD-associated nightmares include clonidine, atypical antipsychotics, topiramate, trazodone, and tricyclic antidepressants, but notes that clonazepam and venlafaxine are not recommended for nightmare disorder 2, 6

Clonidine, an α2-adrenergic receptor agonist, may be considered as an alternative to prazosin, with dosing ranges from 0.2 to 0.6 mg in divided doses, and has been used as a mainstay of PTSD treatment for severely traumatized patients, according to the American Academy of Sleep Medicine 7
The American Academy of Sleep Medicine recommends clonidine as a Level C recommendation, with evidence showing it reduced nightmares in 11/13 patients in case series, although it shares prazosin's potential for postural hypotension and may cause sedation 7
Trazodone (25-600 mg, mean 212 mg) decreased nightmares in 72% of veterans, but 60% experienced side effects including daytime sedation, dizziness, headache, priapism, and orthostatic hypotension, as reported in the Journal of Clinical Sleep Medicine 8
Atypical antipsychotics (olanzapine, risperidone, aripiprazole) may be considered for treatment-resistant cases, with limited evidence, according to the American Academy of Sleep Medicine 8
Topiramate, gabapentin, and low-dose cortisol (10 mg/day) have limited evidence but may be options for treating night terrors, as suggested by the Journal of Clinical Sleep Medicine 7, 8

The American Academy of Sleep Medicine recommends Image Rehearsal Therapy (IRT) as the first-line intervention for PTSD-associated nightmares when prazosin is not tolerated, with a "recommended" designation 9

The American Academy of Sleep Medicine lists atypical antipsychotics, such as olanzapine, risperidone, and aripiprazole, as options that "may be used" for PTSD-associated nightmares 9
The American Academy of Sleep Medicine also lists topiramate, gabapentin, and phenelzine as agents that "may be used" for PTSD-associated nightmares 9
Phenelzine (45-75 mg) eliminated nightmares entirely within 1 month in a small case series, with 3 out of 5 patients remaining nightmare-free without medication, but it can cause hypertensive crisis with sympathomimetic medications or high-tyramine foods 10

The American Academy of Sleep Medicine specifically does not recommend clonazepam and venlafaxine for nightmare disorder 9

Patients with baseline low blood pressure or who are at high risk for falls should be carefully evaluated before starting prazosin, because orthostatic hypotension is the most frequently reported adverse event that requires monitoring, as noted by the American Academy of Sleep Medicine. 11