Anyone can have nightmares, but up to 80% of people with PTSD experience nightmares as a symptom of their PTSD. The idea for this came from an article that SkinnyHobbit shared about the treatment of nightmares, which is based on recommendations from the American Academy of Sleep Medicine in 2018.
What can worsen nightmares
Some medications can potentially increase nightmares, including:
- antidepressants (which can also cause more vivid dreams) and other medications that affect the neurotransmitters serotonin, norepinephrine, and dopamine
- antihistamines
- sedatives/hypnotics like benzodiazepines and alcohol
- certain cardiac/blood pressure meds like beta blockers and calcium channel blockers
- statins for high cholesterol
Medication options
The studies that the American Academy of Sleep Medicine based their recommendations on all involved combat veterans with PTSD, so it’s not clear how much is transferable to complex PTSD. The evidence base is a bit flimsy, so this information is more a matter of something is better than nothing rather than being clear evidence that these medications work really well across the board.
Prazosin: This has been the most studied and has the most evidence to support its effectiveness. It acts on alpha-1 adrenergic receptors, and one of the results of this is to decrease the brain’s activation of the sympathetic nervous system (which is involved in the fight or flight response). That same action on alpha-1 receptors elsewhere in the body can also cause a decrease in blood pressure, which may make this an unsuitable option for some people.
Clonidine: Clonidine acts on alpha-2 adrenergic receptors, and similar to prazosin, it suppresses sympathetic nervous system activation in the brain. It also suppresses REM sleep, which is the sleep phase in which nightmares occur.
Nabilone: Nabilone is a synthetic medication that works at cannabinoid receptors. I did a quick look for studies involving cannabis, and it looked like a bit of a mixed bag, with cannabis being helpful for nightmares in the short term, but in the longer term, that benefit may not be sustained, and some other PTSD symptoms could potentially worsen.
Cyproheptadine: Cyproheptadine is an antihistamine that also acts on a type of serotonin receptors. It’s sometimes used as an appetite stimulant. In a retrospective chart review, patients who experienced a benefit with cyproheptadine (which wasn’t everyone who took it) had either no or significantly reduced nightmares after 3–4 weeks.
Trihexyphenidyl: Trihexyphenidyl is an anticholinergic medication. In a small exploratory study in Japan published in 2021, it was associated with reduced nightmares and flashbacks in treatment-resistant PTSD, and it had a rapid onset of action.
Anticonvulsants
Topiramate: Topiramate is an anticonvulsant that acts in a number of different ways, but it’s unclear which of these ways is responsible for its effect on nightmares. It’s also used for migraines, and it tends to suppress appetite. In one study, 79% of patients taking topiramate experienced a reduction in their nightmares, and 50% stopped having nightmares altogether.
Gabapentin: Gabapentin does a few different things. It’s an anticonvulsant, but it can also help with neuropathic pain, anxiety, and sleep. Only one small study was reported to support its use for nightmares.
Psych meds
Olanzapine/risperidone/aripiprazole: The atypical antipsychotics olanzapine, risperidone, and aripiprazole have shown some benefit for nightmares associated with PTSD. It may be properties other than their antipsychotic activity (via dopamine receptors) that make these particular drugs helpful for PTSD nightmares, so the benefit may not translate to other antipsychotics also being effective.
Fluvoxamine: Fluvoxamine is an SSRI antidepressant. SSRIs generally aren’t recommended, but fluvoxamine may be helpful based on properties other than the SSRI aspect. There are a couple of small studies that have demonstrated some benefit.
Phenelzine: Phenelzine is an MAOI antidepressant. It can cause a lot of side effects, and taking it requires following a tyramine-reduced diet. There may be some benefit for nightmares, but for most people, it would probably be more bother than it’s worth unless there’s treatment-resistant depression accompanying the PTSD.
The benzodiazepines triazolam and nitrazepam are sometimes used in non-PTSD-associated nightmare disorder, but aren’t recommended for people with PTSD nightmares. Clonazepam is also not recommended.
Other options
Psychological treatments can also be helpful in reducing nightmares. One of the recommended treatments is image rehearsal therapy. This involves altering typical nightmare content and replacing it with something more positive, then mentally rehearsing it for 10-20 minutes daily during waking hours. Exposure, relaxation, and rescripting therapy (ERRT) is a similar therapy that also involves sleep hygiene, progressive muscle relaxation, and exposure work.
From a bigger picture perspective, if nightmares are a symptom of PTSD, getting effective trauma treatment, such as EMDR (eye movement desensitization and reprocessing), should help with nightmares. In the meantime, though, getting enough sleep is an important part of the healing process, so that may warrant adding nightmare-specific interventions.
It’s not really a lot to go on, but something is better than nothing, especially when sleep is so important for mental health. Have you ever had treatment for nightmares? If so, how did that work out for you?
References
- Callen, E. D., Kessler, T. L., Brooks, K. G., & Davis, T. W. (2018). Management of nightmare disorder in adults. US Pharmacist, 43(11), 21-25.
- Morgenthaler, T. I., Auerbach, S., et al. (2018). Position paper for the treatment of nightmare disorder in adults: an American Academy of Sleep Medicine position paper. Journal of Clinical Sleep Medicine, 14(6), 1041-1055.
Related posts
There’s more on sleep-related issues in the post What Is… Sleep and Dreaming.
For more info and MH@H posts on psychiatric medications, visit the Psych Meds Made Simple page. There’s also a Psych Meds 101 series covering:
Ashley L. Peterson
BScPharm BSN MPN
Ashley is a former mental health nurse and pharmacist and the author of four books.
So weird that you posted this just as I picked up my phone to call my dr about my nightmares 😂🤦♀️ they are absolutely exhausting me. I’m on 150 quetiapine on a night and zopiclone prn which helps to knock me out but my nightmares are so bad at the minute 😩 I’m scared to go to sleep! Xx
Yikes! I hope you can find something that helps!
Thanks me too. I’m coming through the other side of a crisis (I hope) it’s just these bloody dreams. I wish I could take my brain out and stick it in a jar like dentures 😂 sterilise the bad memories out of it whilst I sleep. Xx
❤️❤️❤️
Interesting! I take prazosin for PTSD nightmares. I think I need a higher dose. Taking a nap can be hell.
Oh that sucks…
Thanks so much for this helpful article! I take topiramate at a low dose (25mg at night) for my C-PTSD. What I’ve noticed is that in addition to reducing my nightmares significantly, it also helps me be less susceptible to being triggered during the day. As a side note, I had no idea risperidone and aripiprazole could lessen nightmares. In fact, I experienced more vivid dreaming on both of them.
I’m glad the topiramate is helping.
It’s interesting that certain antipsychotics and antidepressants can be helpful, but in general, antipsychotics and antidepressants are likely to make dreams more vivid. I’m guessing it wouldn’t be the first choice to try using meds that could help nightmares, but there’s also a pretty good chance they could make them worse…
Prozosin even at low dose lowered our blood pressure so much it made us sick. Trading nightmares for nausea every day wasn’t effective at easing suffering.
We miss benzos soooooo much 😢
We decided our nightmares have something to tell us, but addressing them is exhausting. It gets the back burner. In the end, we suffer anyway.
Overall therapy and treatment may help in the long run. Of course, death will also take care of it in the long-run 🙄
We have so much stress we are walking about 4am each morning and struggling to return to sleep. Remaining calm is our best move at that point, which we can sometimes do for up to 90 minutes. Then we lose our shit 😂
Holding off for 90 minutes is pretty good!
Someone needs to come up with a magic drug that has all the upsides of benzos without any of the downsides. A little dose of sanity to make everything else that needs to be done just a little bit easier…
I tried prazosin. It was the worst. I take 5 mg of olanzapine. Deep and dreamless sleep.
I’m glad the olanzapine helps!
I’ve never been treated for nightmares, but if I forget to take my antidepressants I get frequent, vivid dreams. Not necessarily nightmares, but I rarely remember my dreams, so it stands out to me. Good indicator that I forgot my pill the previous day.
I’ve not long finished two courses of EMDR. Although it definitely helps overall the nightmares definitely got pretty intense after a session for a couple days.
Ugh.
Done therapy, sort of. 1990’s era treatment.
The French médecin and me parted ways because of all the drugs he gave me.
Uppers, downers, and zombie drugs by the bucket full.
I mean what is life if you can’t even remember your name?
Anyway, it must have been something I said.
Or was it what I did.
We will never know as I can’t remember how I bruised my knuckles.
So, 36 years later I still get nightmares, but now know them as that.
Knowing equals coping, so I do manage to get some sleep.
As for the times I can’t cope?
I’m way too old to care about what modern science says you should do and still use a wonderful soporific that I discovered when working in Deepest Europe.
Slivovitz. Instant black sleep and no nasty side or after effects.
Whatever works!
Exactly. Keep up the good work Ashley.
Oh I’m thrilled to read this post because the scientific article was hard to understand and I kept forgetting the link. Thanks to you, I can share your post with my other CPTSD/PTSD friends, including those off WordPress 💙
Ooh melatonin (supplement) gave me more nightmares.
And medication Induced nightmares suck.
Ugh, worsening nightmares is not a good thing.
Yeah and I feel like maybe patients don’t get told a lot of side effect info. Could be just my country though, I rarely get a information pamphlet on my medication. Was rather concerned when brexpiprazole
gave me dizziness significant enough to impact my life, as I’d never experienced such a side effect. And it turned out to be a “common” side effect.
I wouldn’t say it’s common. Based on prescribing info, orthostatic hypotension and syncope occur in less than 2% of people who take it. That’s still going to happen in a decent number of people, and it should be on an info pamphlet if you were given one, but if, let’s say, they were to tell you the ten most common side effects, that wouldn’t make the list.
Thank you, that makes sense to me. ❤
This was most helpful. It jingled my bells. Thank you.
A lot of MY nightmares happen when awake.
Thank you for highlighting the importance of responsible prescribing and the use of these medications! Each individual is unique, and thus, treatment plans should be tailored to the person’s needs and medical history. If you’re considering to get prescribed Xanax or any other benzodiazepine, it is crucial to have an in-depth discussion with your healthcare provider about your symptoms, concerns, and expectations. Take care of your health.