Prazosin for Nightmares

Prazosin for Nightmares

by Julia -

Although I don't have much personal experience prescribing/working with prazosin myself, I have always considered it to be a first line treatment for individuals with PTSD. In my clinical rotations so far I've seen prazosin used to treat nightmares and symptoms of PTSD, and it seems as though it is effective. Like many, therefore, I was surprised to read this article and see that in this particular study, prazosin was not an effective treatment for nightmares associated with PTSD. 

There are a few flaws of the study that make me questions the generalizability of the results. The exclusion criteria seem to have been quite strict (no psychotic or cognitive disorders, no substance dependence within the last 3 months, no cocaine or stimulant use, no active SI/HI, to psychosocial instability). It is always challenging to balance the need to limit potential confounding variables while maintaining a realistic eligibility criteria. It seems, though, that the exclusion criteria, especially the vague "psychosocial instability" exclusion criterion may explain why the results of this study contradict what we all seemed to know about prazosin and PTSD. 

At this point there is still a thorough discussion of the benefits of using prazosin for PTSD nightmares on UpToDate that cites multiple studies showing its efficacy (https://www.uptodate.com/contents/nightmares-and-nightmare-disorder-in-adults?sectionName=Prazosin&anchor=H4261530858&source=see_link#H4261530858). 

I think that given clinical experience (both mine and my colleagues), as well as the current recommendation on UpToDate, I will continue to view prazosin as a tool to use when treating individuals with PTSD and nightmares. I plan to keep this article in the back of my mind for times when prazosin does not work, however at this point I don't see myself changing my views/practice based on this article. 


Re: Prazosin for Nightmares

by Michelle -

Thanks for the post, Julia. I came to similar conclusions as you did when reading this article and discussing it in our journal club. The results of this multisite RCT definitely made me rethink what I thought I knew about PTSD nightmares. Prazosin seems to be the main tool in our toolkit that we are talking about. Additionally, I have seen a lot of clients who endorse the medication and feel that it really helps to reduce their symptoms. However, I, like you, will keep this article in the back of my mind as I treatment plan with my clients. Recently, I saw a 15 yo who came to me already having tried prazosin and she stated that it didn't help her at all. She states that she took 4mg and her previous provider discontinued the medication at 4mg since she had no response. Her nightmares are very intense and frequent. As the new provider, I had to think about how to move forward with this client. This article made me think over our options. She had already tried prazosin and saw no effect, however, she stopped at a dose of 4mg when women (adults) are recommended a maximum of 12mg. I thought about if I should discuss re-initiating the medication and titrating up or discussing a different option? I ended up giving the client the option to choose and she chose a different option. 

I would love that as we discuss the potential ineffectiveness of prazosin, if we also mentioned the other options currently available. UptoDate does not have a lot to add to the discussion around nightmares other than prazosin, mostly because it is the most studied. UpToDate mentions that studies have shown the children usually find prazosin effective at doses of 5 or less, however adolescents may require more than 5mg. UpToDate also mentions potential options to help with hyperarousal and sleep, including gaunfacine and clonidine, which have been shown to be safe in the pediatric population for other indications. We ended up starting the client on clonidine as she also was having trouble falling asleep and difficulty with concentrating at school. She found that the nightmares are less often and less intense but still regularly occurring. 

This article was helpful to reframe how we think about Prazosin, but like you mentioned, the article might not be the most generalizable so it is important to think critically about the client in front of you and utilize shared decision making to find the best option. Thanks for your thoughts, Julia! 


Strawn, J. & Keeshin, B. (2017). Pharmacotherapy for post traumatic stress disorder in children and adolescents. In D Brent (Ed.). UpToDate. Retireved from https://www.uptodate.com/contents/pharmacotherapy-for-posttraumatic-stress-disorder-in-children-and-adolescentssearch=nightmares%20children&source=search_result&selectedTitle=6~150&usage_type=default&display_rank=6#H3158245362