Does nortriptyline help with chronic pain?
Nortriptyline, a tricyclic antidepressant, reduces chronic pain by blocking reuptake of norepinephrine and serotonin, which modulates pain signals in the spinal cord and brain.[1] Clinical trials show it eases neuropathic pain like diabetic neuropathy and postherpetic neuralgia, with moderate evidence from Cochrane reviews: 30-50% of patients achieve 50% pain reduction at doses of 25-100 mg daily, outperforming placebo by 20-30%.[2][3]
How effective is it for specific pain types?
- Neuropetic pain: Strongest data here; a 2015 meta-analysis of 29 trials found number needed to treat (NNT) of 3.6 for 50% relief in peripheral neuropathy.[4]
- Fibromyalgia: Helps pain and sleep; trials report 20-40% improvement vs. placebo.[5]
- Other chronic pains: Mixed results for migraine prophylaxis (reduces frequency by 25-50%) and tension headaches; weaker for osteoarthritis or low back pain.[6]
- Central pain (e.g., multiple sclerosis): Small studies show benefit, but evidence is limited.[3]
Effect builds over 2-4 weeks; full response may take 6-8 weeks.[1]
How does nortriptyline compare to other pain meds?
Better tolerated than amitriptyline for pain (fewer dropouts due to side effects).[2] Versus SNRIs like duloxetine: similar efficacy for neuropathy (NNT ~4-5), but nortriptyline is cheaper and generic.[4] Duloxetine edges out for fibromyalgia.[5] Gabapentinoids (pregabalin) match it for neuralgia but cause more dizziness.[6] Guidelines (NICE, ACP) recommend it as first- or second-line for neuropathic pain.[7][8]
| Drug | NNT for 50% neuropathic pain relief | Common side effects |
|------|-------------------------------------|---------------------|
| Nortriptyline | 3.6 [4] | Dry mouth, sedation |
| Duloxetine | 4.8 [4] | Nausea, fatigue |
| Pregabalin | 4.2 [6] | Dizziness, weight gain |
| Amitriptyline | 3.1 [2] | More anticholinergic effects |
What side effects limit its use?
Dry mouth (40-70%), constipation (20-30%), sedation (30%), and weight gain affect adherence; 20-25% discontinue.[2] Cardiac risks (QT prolongation) in elderly or heart patients; start low (10-25 mg) at bedtime.[1] Avoid in glaucoma or prostate issues due to anticholinergic effects.[9]
Who should avoid it, and what are the risks?
Contraindicated with recent MAOIs, acute recovery from MI, or arrhythmias.[9] Overdose risk high (seizures, coma); black box for suicidality in young adults.[1] Elderly: higher fall risk from orthostasis.[10] Drug interactions: raises levels with SSRIs or CYP2D6 inhibitors.[9]
How is it dosed for pain vs. depression?
Pain: Titrate from 10-25 mg nightly to 75-150 mg (max 150 mg); lower than depression doses (75-300 mg).[1][3] Monitor ECG if >100 mg or cardiac history.[9]
Is it available generically, and what's the cost?
Generic since 1990s; no active patents per DrugPatentWatch.com.[11] Monthly cost: $10-30 US (generic); often covered by insurance for pain.[12]
[1] Lexicomp. Nortriptyline. UpToDate, 2023.
[2] Moore RA, et al. Cochrane Database Syst Rev. 2015.
[3] Finnerup NB, et al. Lancet Neurol. 2015.
[4] Derry S, et al. Cochrane Database Syst Rev. 2015.
[5] Häuser W, et al. Cochrane Database Syst Rev. 2013.
[6] Wiffen PJ, et al. Cochrane Database Syst Rev. 2013.
[7] NICE. Neuropathic pain guideline. 2020.
[8] Qaseem A, et al. Ann Intern Med. 2017.
[9] FDA. Pamelor label. 2022.
[10] American Geriatrics Society. Beers Criteria. 2019.
[11] DrugPatentWatch.com. Nortriptyline patents. Accessed 2023.
[12] GoodRx. Nortriptyline pricing. 2023.