To evaluate the association between once-nightly pregabalin use and changes in nightmare frequency, restorative sleep, headache frequency, severity, duration, and disability scores in patients with nightmare, nonrestorative sleep, and headaches.

Nightmares, nonrestorative sleep, and headaches co-occur, are common, underdiagnosed, and contribute to substantial disability. Pregabalin’s effect on nightmares has not been systematically studied. Sedation is a common side effect when prescribed 2-3 times daily according to the package insert, but the literature assessing once nightly use is sparse.

Our retrospective case series included 23 patients prescribed once nightly pregabalin for nightmares, nonrestorative sleep, and headaches. Clinical data were extracted from medical records, including nightmare frequency, fraction of 24-hour periods with restorative sleep, headache frequency, severity, and duration, and Migraine Disability Assessment Questionnaire (MIDAS) scores. Within-subject pre–post comparisons were performed using paired t-tests or Wilcoxon signed-rank tests. All p-values were Holm–Bonferroni adjusted.

Nightmare frequency decreased 81% (17.5 to 3.3/month, p_adj=.006). Nightmares decreased numerically more for those who transitioned from gabapentin to pregabalin (91%) than for those not initially taking gabapentin (73%). Restorative sleep frequency increased 127% (1.8 to 4.0/week, p_adj=.006). Headache frequency decreased 50% (17.0 to 8.5/month, p_adj=.040). Migraine Disability Assessment Questionnaire (MIDAS) scores decreased numerically by 35% (44.0 to 24.5) but did not reach statistical significance after correction (p_adj=.084). Six patients reported side effects, and 19 continued pregabalin at three months.

Once nightly pregabalin use was associated with robust reductions in nightmare frequency, nonrestorative sleep, and headache frequency. The reduction in nightmares is a novel finding. Nightmares improved even among patients transitioning from gabapentin to pregabalin, suggesting that pregabalin may be superior to gabapentin. No prior studies have addressed these three co-occurring problems simultaneously. Larger controlled studies are needed to test the hypothesis that once nightly pregabalin may be a useful treatment for this patient population.