Treatment of Nightmares in Adults

Pharmacological Treatment

The American Academy of Sleep Medicine recommends clonidine (0.2-0.6 mg in divided doses) as the best alternative pharmacological option for the treatment of nightmares in the absence of prazosina, followed by trazodone (average dose of 212 mg/day) as a second line 1, 2
Clonidine, an α2-adrenergic receptor agonist, has been shown to reduce nightmares in 11/13 patients in case series, with a recommended dose of 0.2-0.6 mg in divided doses 1, 2
Trazodone has demonstrated a significant reduction in nightmare frequency from 3.3 to 1.3 nights/week (p < 0.005), with an average effective dose of 212 mg/day 3, 2
The American Academy of Sleep Medicine suggests considering antipsychotic medications, such as risperidone (1-3 mg/day) and olanzapine (10-20 mg), as third-line options, although evidence is limited 3, 1, 2

The American Academy of Sleep Medicine strongly recommends Image Rehearsal Therapy (IRT) as the most effective non-pharmacological intervention, demonstrating a 60-72% reduction in nightmare frequency with sustained effects at 6-30 months 4, 5

Blood pressure monitoring, especially orthostatic, is crucial when using clonidina or trazodona 1, 2
Clinicians should be aware of the risk of priapism with trazodone, requiring immediate discontinuation 3
Response to treatment should be assessed after 2-8 weeks, with monitoring of adverse effects, particularly daytime sedation 1, 3, 2