Medications That Can Help with Nightmares in PTSD

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.