Background   Good, restful sleep is essential to quality of life – providing renewed energy for the next day.  Nightmares are vivid, frightening dreams that typically lead to full awakening with detailed recollection of the dream sequence and content.  Following a nightmare, heart rate and blood pressure are elevated, and residual anxiety may interfere with the ability to return to sleep.  Nightmares occur almost exclusively during REM (Rapid Eye Movement) sleep.   

Causes 

• Psychiatric.  Anxiety is a common symptom during a life-threatening illness.  Specifically, anxieties related to the illness course and prognosis, procedures and treatments, family issues, and death, can be significant.  Nightmares may arise as a complication of anxiety or other psychiatric disturbances (such as post-traumatic stress disorder, delirium, mood disorders, schizophrenia, and adjustment disorders).
• Medications/Drugs/Alcohol.  Medications causally linked to nightmares include: beta-blockers, sedative/hypnotics, amphetamines and other stimulants, dopamine agonists, and antidepressants.  Withdrawal from REM-suppressing drugs, including antidepressants, benzodiazepines, and alcohol, predisposes to the development of nightmares.
• Brain disorders.  CNS infections, brain tumors and other structural problems of the brain may lead to nightmares.
• Metabolic: hypoglycemia. 

Psychotherapeutic interventions from a trained mental health professional can be particularly helpful for people whose nightmares are related to stress/anxiety or an underlying psychiatric condition. 

• Several randomized controlled trials support the efficacy of “image rehearsal therapy” (IRT) in the treatment of nightmares. This is a modified cognitive behavioral therapy (CBT) technique involving creating and rehearsing alternative, positive mental images during the day.  IRT is now recommended as first-line therapy for nightmares.
• Additional effective modalities of psychotherapy for nightmares include CBT, exposure, relaxation, and rescripting therapies, and “eye movement desensitization and reprocessing therapy” for those with post-traumatic stress disorder who suffer nightmares. 

Pharmacologic management    The pharmacologic treatment of nightmares have not been as well studied as psychotherapeutic interventions, still they may have a role in refractory cases.   

• Prazosin: An alpha-1 adrenergic receptor antagonist that has shown utility in patients who remain symptomatic after psychotherapy. Dosing begins at 1 mg by mouth at night and can be titrated weekly with effective doses ranging from 3 – 16 mg nightly. Slow titration can minimize vasomotor adverse effects. While benefit can be seen earlier, full therapeutic effect may not be seen for eight weeks. Many patients can taper therapy after several months of efficacy.
• Other agents: data suggest trazodone, gabapentin, clonidine, cyproheptadine topiramate, terazosin, olanzapine, and risperidone may reduce psychological distress from nightmares in select patients.
• Benzodiazepines and tricyclic antidepressants may be useful in suppressing REM activity, but there is not well-established data to suggest their efficacy in treating nightmares.   

References 

1. Skeie-Larsen, M et al. The Effects of Pharmacological Treatment of Nightmares: A Systematic Literature Review and Meta-Analysis of Placebo-Controlled, Randomized Clinical Trials. Int Jrnl of Environmental Research and Public Health. 2023; 20(1):777.
2. Morgenthaler, TI et al. The Treatment of Nightmare Disorder in Adults: An American Academy of Sleep Medicine Position Paper. 2018; 14(6): 1041-1055.
3. Zak R et al. Nightmares and Nightmare Disorder in Adults. UpToDate. Oct 2023.
4. Buysse DJ et al. In: Gabbard G, ed. Treatments of Psychiatric Disorders, 2nd Edition. Washington, DD: American Psychiatric Press; 1995: pp2395-2453.
5. Sateia MJ et al.  In: Doyle D, et al, eds. Oxford Textbook of Palliative Medicine, 2nd Edition. New York, NY: Oxford University Press; 1998: pp751-767.
6. Krakow B et al. Imagery Rehearsal Therapy for Chronic Nightmares in Sexual Assault Survivors with Posttraumatic Stress Disorder: A Randomized Controlled Trial. JAMA. 2001; 286(5):537-545.
7. Labbate LA. Olanzapine for Nightmares and Sleep Disturbance in Posttraumatic Stress Disorder [comment]. Can J Psych. 2000; 45(7):667-668.
8. Taylor, FB et al.  Prazosin Effects on Objective Sleep Measures and Clinical Symptoms in Civilian Trauma Posttraumatic Stress Disorder: A Placebo-Controlled Study.  Biol Psychiatry.  2008; 15:629-32.

Version History:  This Fast Fact was originally edited by David E Weissman MD. 2nd Edition was edited by Drew A Rosielle and published October 2007; 3rd Edition June 2015; 4th Edition by Dr. Kerry Case in July 2024.
Conflicts of Interest: None to report.