Trauma and PTSD

Medications That Can Help with Nightmares in PTSD

Medications that can help with nightmares: cartoon of scared person in bed

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 decrease the brain’s activation of the sympathetic nervous system (which is involve 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 3โ€“4 weeks.

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 makes 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?

Sources

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:

34 thoughts on “Medications That Can Help with Nightmares in PTSD”

  1. So weird that you posted this just as I picked up my phone to call my dr about my nightmares ๐Ÿ˜‚๐Ÿคฆโ€โ™€๏ธ they are absolutely exhausting me. Iโ€™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 ๐Ÿ˜ฉ Iโ€™m scared to go to sleep! Xx

      1. Thanks me too. Iโ€™m coming through the other side of a crisis (I hope) itโ€™s just these bloody dreams. I wish I could take my brain out and stick it in a jar like dentures ๐Ÿ˜‚ sterilise the bad memories out of it whilst I sleep. Xx

  2. 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.

    1. 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…

  3. Fascinating! I ought to look into this. I have recurring nightmares that I or someone else in the dream is being humiliated and violated, and the dreams make me sick and make me feel humiliated; and I’ve gotten incredibly adept at waking up and putting it behind me, but geez. I can never envision a solution because making nightmares go away won’t make the realities of kids being mistreated go away, if that makes any bizarre sense. I do take Abilify (that’s the aripiprazole, right?), but just a low dosage. And sometimes the dreams shift between being humiliating and being arousing, which makes me feel sick about who I am. ๐Ÿ™ And sometimes they’re all arousing, but I don’t want to feel so perverted about it all. I wake up, feel bad about who I am, and then just forget it. But it doesn’t happen all the time, so that’s good!

    1. I wonder if that’s where something like image rehearsal therapy could help with trying to tack on an ending of a hero riding in a glitter-farting unicorn to save whoever is being harmed. And said hero could be hot, which could make for a good shift of arousal focus…

  4. Prozosin even at low dose lowered our blood pressure so much it made us sick. Trading nightmares for nausea every day wasnโ€™t effective at easing suffering.

    We miss benzos soooooo much ๐Ÿ˜ข

    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 ๐Ÿ™„

    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 ๐Ÿ˜‚

    1. 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…

  5. Ooooh, not a bad idea!! I like that! He could say, “I will save the innocent children with my lance and my fire-breathing dragon! Come with me, children, to a magical land where you’ll always be respected.” I like that!! ๐Ÿ˜€ Thanks!!

  6. 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.

  7. Done therapy, sort of. 1990’s era treatment.
    The French mรฉdecin 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.

  8. 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 ๐Ÿ’™

      1. 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.

        1. 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.

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