Adverse Child Experiences (ACEs), or traumatic experiences, have significant medical and psychological sequelae.  ACES may or may not lead to post traumatic stress disorder, and regardless of the presence of a formal diagnosis, exposure to ACEs increase the risk for poor sleep and traumatic nightmares.  There are many psychotherapeutic and resiliency enhancing ways to support youth and families with ACES (ACESAWARE.org).  Today we explore the role of medication in treating PTSD associated nightmares.

Prazosin (minipress) is a centrally acting alpha 1 antagonist, decreasing sympathetic tone.  It is an FDA approved ant-hypertensive. It is a well-tolerated as an off-label treatment for PTSD-associated nightmares, with a small but significant improvement in sleep and decrease in nightmare frequency (Kung et al. 2012).  In 2018, Raskind and others published findings from the PACT study, a randomized control trial which called into question the effectiveness of prazosin for PTSD associated nightmares in combat veterans (Raskind 2018). There were some limitations to the generalizability of this study, such as no non-combatants in the sample. Overall, when evaluating the cumulative research data, there is still a consensus that there is a role prazosin as a therapeutic for trauma-related sleep disturbance (Kendrick et al, 2021).

Alpha agonists, such a clonidine and guanfacine, have been safely used for the treatment of ADHD in youth and adults.  While there is some evidence for the role of these agents in PTSD associated nightmares, given the paucity of studies, prazosin would likely by the first agent of choice.

• Prazosin is well a tolerated treatment for PTSD-associated nightmares with a small but significant improvement in sleep and decrease in nightmares
  • Adolescents – 1 – 4 mg
    • No FDA indication
    • No RCTs, but systematic review is positive (Akinsanya et al. 2017)
  • Adult doses vary but generally 1 – 10 mg, with higher doses for men.
    • No FDA indication
    • Varying evidence, still
• Clonidine has been used to treat PTSD (Aloa et al. 2021)
  • No FDA indication
  • Dosing less well studied and Limited studies in adolescents

References:

AcesAware.org

Akinsanya A, Marwaha R, Tampi RR. Prazosin in Children and Adolescents With Posttraumatic Stress Disorder Who Have Nightmares: A Systematic Review. J Clin Psychopharmacol. 2017 Feb;37(1):84-88. doi: 10.1097/JCP.0000000000000638. PMID: 27930498.

Alao A, Selvarajah J, Razi S. The use of clonidine in the treatment of nightmares among patients with co-morbid PTSD and traumatic brain injury. Int J Psychiatry Med. 2012;44(2):165-9. doi: 10.2190/PM.44.2.g. PMID: 23413663.

Kendrick, J, Adamczyk, R, Thomas, C, 2021. “Prazosin Prazosin for PTSD: Sorting out the evidence Current Psychiatry. 2021 April;20(4):39-41 | doi:10.12788/cp.011

Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic Proceedings, 87(9), 890–900. https://doi.org/10.1016/j.mayocp.2012.05.015

Raskind MA, Peskind ER, Chow B, et al. Trial of prazosin for post-traumatic stress disorder in military veterans. N Engl J Med. 2018;378(6):507-517.