Treatment of Nightmares

Introduction to Nightmares

Nightmares can be effectively managed with behavioral therapies and pharmacological interventions, as recommended by the American Academy of Sleep Medicine 1

The American Academy of Sleep Medicine recommends Imagery Rehearsal Therapy (IRT) as the first-line treatment for nightmares, which involves having the patient recall the nightmare, write it down, change the theme or ending to a more positive one, and rehearse the rewritten dream scenario for 10-20 minutes daily, with Level A evidence 1
Progressive Deep Muscle Relaxation (PDMR) has been shown to reduce nightmare frequency by up to 80%, with Level B evidence, and involves tensing and releasing muscles systematically to induce physical relaxation, practiced for 15-20 minutes daily 1
Systematic Desensitization is particularly effective for reducing nightmare intensity, with Level B evidence, and involves gradually exposing the patient to anxiety-provoking elements of the nightmare 1
Exposure, Relaxation, and Rescripting Therapy (ERRT) combines exposure procedures with relaxation training, with Level C evidence, and includes psychoeducation, sleep hygiene, and progressive muscle relaxation 1
Eye Movement Desensitization and Reprocessing (EMDR) is particularly effective for PTSD-associated nightmares, with Level C evidence, and uses bilateral eye movements, tones, and taps to process disturbing memories 1
Hypnosis creates a state of deep relaxation to address nightmare content, with Level C evidence, and brief hypnotic therapy of 1-5 sessions can be beneficial 1

The American Academy of Sleep Medicine strongly supports behavioral approaches as first-line treatment for nightmares, with pharmacological interventions reserved for cases that fail to respond to behavioral approaches, with Level A evidence 1
The American College of Physicians recommends Cognitive Behavioral Therapy for Insomnia (CBT-I) as a first-line treatment for chronic insomnia 2
Implementing sleep hygiene practices, starting Image Rehearsal Therapy (IRT) and/or Cognitive Behavioral Therapy (CBT), and tracking nightmare frequency and intensity using sleep diaries is recommended as the initial approach, as stated by the American Academy of Sleep Medicine 3
Good sleep hygiene practices, avoiding alcohol use, maintaining a regular sleep-wake schedule, and avoiding heavy meals throughout the day are recommended for patients with sleep disorders, as stated by the American Geriatrics Society 4

Prazosin, with a dosing range of 1-10+ mg daily, reduces nightmare frequency by >50% compared to 15% with placebo, and benefits may appear within one week of initiation, with a Level A recommendation from the American Academy of Sleep Medicine 3
Trazodone, with a dosing range of 50-200 mg nightly, decreases nightmare frequency from 3.3 to 1.3 nights/week in 72% of patients, and helps with both sleep onset (92%) and maintenance (78%) 5
Clonidine is recommended as an alternative treatment for nightmares in PTSD patients, with a Level C recommendation and a starting dose of 0.1 mg twice daily, titrating up as needed 5, 1
SSRIs (sertraline, paroxetine, fluoxetine) are recommended for underlying panic disorder, which may take 2-4 weeks to show full effect, and are better tolerated than TCAs with fewer dropouts (18% vs 31%) 3
The following treatment options are recommended, with their corresponding doses and levels of evidence:

Patients taking prazosin should be monitored for orthostatic hypotension, especially after the first dose, and blood pressure should be monitored during treatment, as per the American Academy of Sleep Medicine guidelines 5
Male patients taking trazodone should be directly asked about priapism as a potential side effect 5
Common side effects of trazodone include daytime sedation or dizziness (60% of patients), priapism (12% of patients), dry mouth/sinuses, muscle pain, and agitation 5

For children, most outgrow night terrors by late adolescence, and anticipatory awakening may be considered 5
For PTSD-related nightmares, combining CBT for insomnia with IRT or ERRT may be considered 5
Clonidine is recommended for children ≥12 years with an initial dose of 0.1 mg at bedtime, as suggested by the American Academy of Pediatrics 6
The maximum dose of clonidine is generally not exceeding 0.3 mg/day in children, as recommended by the American Academy of Child and Adolescent Psychiatry 7

Underdosing prazosin, failing to monitor blood pressure during medication treatment, discontinuing treatment prematurely, relying solely on pharmacological treatment, using medications specifically not recommended (clonazepam, venlafaxine), and attempting to interrupt a sleep terror episode should be avoided, as per the American Academy of Sleep Medicine guidelines 5, 1
Using medications not recommended for nightmare disorder, such as clonazepam and venlafaxine, should be avoided, as per the American Academy of Sleep Medicine guidelines, with the goal of minimizing potential harm, as reported by the American Academy of Sleep Medicine 5, 1