Effective Treatment of Night Terrors and Sleepwalking with Ramelteon

To the Editor:

Night terrors and sleepwalking are parasomnias that typically occur during the slow-wave nonrapid eye movement sleep stage. The symptoms often subside with age, and therefore, no treatment is required for most children. However, children with these disorders must be protected from sustaining injuries during the episodes. In severe cases, low doses of benzodiazepines are commonly administered for night sedation (Remulla and Guilleminault 2004). However, benzodiazepines should be used with caution in children because of their potential for tolerance and dependency. Here, we report a boy whose night terrors and sleepwalking were effectively treated with ramelteon.

An 11-year-old boy with attention-deficit/hyperactivity disorder (ADHD) was referred to our child psychiatry outpatient clinic because of sleeping difficulties. His past history revealed that he was an active child, always running and climbing on things. His night terrors and sleepwalking began at age 7, when his sleeping difficulties began after being hospitalized because of an injury from an accidental fall from a tower. He was diagnosed with ADHD and was started on atomoxetine at the age of 8. His mother, who had abused and neglected him, was alcohol dependent and died when he was 9 years old. Sleepwalking episodes were most frequent, more than once a week, after the death of his mother. Although the episodes gradually became less frequent, sleepwalking continued to occur once a month, necessitating protection from injury at night.

On his first visit, his grandmother, who has been taking care of him, reported that he was frightened every night and suffered difficulty falling asleep. An hour or two after falling asleep, he often cried and screamed, which he did not remember the next day. Episodes of sleepwalking also occurred more than once a month, during which he would walk out of his bedroom. Ramelteon was started at a dose of 4 mg/day. His trouble falling asleep disappeared within a few days, and therefore, ramelteon was discontinued after 10 days of administration. Surprisingly, his night terrors and sleepwalking also subsided promptly along with the improvement of difficulty falling asleep. No recurrence of insomnia or episodes of parasomnias have occurred after 10 months of follow-up.

This report is the first to suggest the possible efficacy of ramelteon, a melatonin receptor agonist, in childhood night terrors and sleepwalking. Improvement of parasomnias provided him a sense of security, which may have led to a virtuous cycle of minimizing the fear of sleep and maintaining good sleeping habits. Two anecdotal reports have shown the efficacy of melatonin therapy in night terrors and sleepwalking (Jan et al. 2004; Ozcan and Donmez 2014). Although the pathophysiology of these parasomnias remains unclear, sleep deprivation and forced arousals during slow-wave sleep are known to induce sleepwalking in predisposed individuals (Pilon et al. 2008). In the present case, improved sleep deprivation because of ramelteon treatment may have corrected the slow-wave sleep dysregulation, resulting in improved parasomnias. The precise mechanism remains to be elucidated, but ramelteon may be an alternative to benzodiazepines in treating children with night terrors and sleepwalking.