Nightmares occur in most adult patients at some point in time. They often occur after a patient experiences a negative or traumatic event in their lives. They are also a symptom of post-traumatic stress disorder (PTSD).
Nightmares are not initially treated because they are such a common event. However, some patients are so affected by nightmares that they can be too scared to go to sleep. In patients with PTSD, they may continue to relive their most traumatic events over and over.
In sleep medicine, clinicians often use the alpha blocker prazosin (Minipress) to control nightmares if the nightmares are overwhelming the patient. Of course, because this medication is an anti-hypertensive drug, caution has to be given when increasing the dose because increased doses of prazosin may lead to hypotension.
Prazosin is not typically used to treat hypertension, as there are better medications on the market. Prazosin controls nightmares by crossing the blood-brain barrier and decreasing sympathetic outflow. It helps block norepinephrine, which is associated with nightmares.
Along with the pharmacological agent prazosin, cognitive behavioral therapy (CBT) has also been used in the past to treat nightmares. It is a recommended therapy for patients with insomnia. Repeated nightmares, arousals from sleep, and fear of sleeping can increase insomnia issues in this patient group.
Currently, imagine rehearsal therapy (IRT), has emerged as a very effective treatment in patients with nightmares. A practitioner using IRT asks the patient to think about their nightmare and then to write a narrative that includes a new, better ending to the dream. The patient is then asked to think about this new dream during the day. The thought is that the new dream will eventually replace the old nightmares.
Although no head-to-head trials exist that compare the effects of prazosin with IRT, a recent meta-analysis published in the Journal of Clinical Sleep Medicine indicated that the combination of CBT and IRT may be more effective in treating insomnia, and improving overall sleep quality and PTSD symptoms compared with prazosin.
This was a limited study, so more work is to be done. I am happy to see that there is an alternative treatment other than medication. Don’t get me wrong, I prescribe prazosin in some of my patients that have recurring nightmares — especially in those with PTSD — but I do think that these patients should work with a therapist to help them overcome the root cause of their problem. Addressing the experiences that have caused these recurring nightmares is very important.