How long does nortriptyline take to work for sleep

Nortriptyline: a medicine used to treat nerve pain and depression

1. About nortriptyline

Nortriptyline is a medicine used for treating nerve pain.

Occasionally, it's also used to treat depression and bedwetting in children (nocturnal enuresis) .

Nortriptyline is available on prescription. It comes as tablets.

2. Key facts

If you take nortriptyline to treat nerve pain, it usually takes a week or so for pain to begin to wear off.
If you take it for depression, it can take 4 to 6 weeks until it reaches full effect.
Common side effects include a dry mouth and constipation. They're usually mild and go away after a couple of weeks.

Nortriptyline can make you feel sleepy so it's best to take it in the evening or before you go to bed.
If your doctor decides to take you off nortriptyline, they will reduce your dose gradually to help prevent withdrawal side effects such as muscle pain or feeling sick or tired.

3. Who can and cannot take nortriptyline

Most adults can take nortriptyline. Teenagers aged 12 to 17 years can take it for depression.

Children aged 6 to 17 years old can also take it for bedwetting but other medicines are used first which have less side effects.

Nortriptyline is not suitable for some people. Check with your doctor before starting to take nortriptyline if you:

have ever had an allergic reaction to nortriptyline or any other medicine
have a heart problem – nortriptyline can make some heart problems worse
have liver or kidney problems
have epilepsy or are having electroconvulsive treatment (ECT) – nortriptyline can increase your risk of seizures or fits
have ever taken any medicines for depression – some antidepressants can affect the way nortriptyline works, even after you've stopped taking them
are pregnant, trying to get pregnant or breastfeeding
have glaucoma – nortriptyline can increase the pressure in your eye
have thoughts about harming yourself or ending your life
have type 1 or type 2 diabetes – if you have diabetes, nortriptyline may affect your blood sugar levels. If you usually test your blood sugar level, you may have to do this more often for the first few weeks of treatment. Talk to your diabetes nurse or doctor if the reading is high or low

4. How and when to take nortriptyline

You'll usually take nortriptyline once a day. If you take it once a day, it's best to take it before you go to bed as it can make you feel sleepy. If you find that it's affecting your sleep, you could try taking it earlier in the evening.

This medicine does not usually upset your stomach. You can take it with or without food.

Swallow the tablets whole, with a drink of water. If you chew them, they taste bitter.

Dosage and strength

Nortriptyline tablets come in 3 different strengths, 10mg, 25mg or 50mg.

The usual dose to treat nerve pain in adults is 10mg a day. This can be increased if necessary. The maximum dose of nortriptyline for treating pain is 75mg a day, but this is only under the supervision of a pain specialist.

For depression in adults, the dose is increased gradually to between 75mg and 100mg a day. It can be increased to a maximum dose of 150mg a day if a specialist prescribes it.

For depression in teenagers (12 to 17 years), the dose is usually increased gradually to 30mg to 50mg a day, but higher doses may be needed.

What if I forget to take it?

If you forget a dose, take it as soon as you remember, unless it's nearly time for your next dose. In this case, just leave out the missed dose and take your next dose at the usual time.

Never take 2 doses at the same time to make up for a forgotten dose.

If you often forget doses, it may help to set an alarm to remind you. You could also ask your pharmacist for advice on other ways to help you remember to take your medicine.

What if I take too much?

Urgent advice: Contact 111 for advice now if:

you take more than your usual dose of nortriptyline

Go to 111.nhs.uk or call 111

Taking too much nortriptyline can cause serious side effects such as a change in your heartbeat, or you may have a seizure or fit.

5. Side effects

Like all medicines, nortriptyline can cause side effects in some people, but many people have no side effects or only minor ones.

Some of the common side effects of nortriptyline will gradually improve as your body gets used to the medicine.

Common side effects

Doses of nortriptyline for pain are lower than the doses for depression. This means the common side effects tend to be milder and go away within a few days.

Keep taking the medicine but talk to your doctor or pharmacist if these side effects bother you or do not go away:

constipation
feeling dizzy
dry mouth
feeling sleepy
difficulty peeing
headaches

Serious side effects

It happens rarely, but some people have a serious side effect after taking nortriptyline.

Contact a doctor if:

your heartbeat becomes fast and irregular
the whites of your eyes turn yellow, or your skin turns yellow, although this may be less obvious on brown or black skin – these can be signs of a liver problem
you have a headache that does not get better, feel confused or weak and have muscle cramps – together these can be signs of low sodium levels in your blood
you have thoughts about harming yourself or ending your life
you have eye pain, a change in your eyesight, or swelling or redness in or around the eye
you have constipation that lasts a long time or problems peeing which are causing stomach ache

Immediate action required: Call 999 or go to A&E if:

you have weakness on one side of your face or body, trouble speaking or thinking, loss of balance or blurred eyesight – these can be signs of a stroke
you have a seizure or fit
you get severe chest pain – this can be a sign of a heart attack

Serious allergic reaction

In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to nortriptyline.

Immediate action required: Call 999 or go to A&E now if:

you get a skin rash that may include itchy, red, swollen, blistered or peeling skin
you're wheezing
you get tightness in the chest or throat
you have trouble breathing or talking
your mouth, face, lips, tongue or throat start swelling

You could be having a serious allergic reaction and may need immediate treatment in hospital.

These are not all the side effects of nortriptyline. For a full list see the leaflet inside your medicines packet.

Information:

You can report any suspected side effect using the Yellow Card safety scheme.

Visit Yellow Card for further information.

6. How to cope with side effects of nortriptyline

What to do about:

constipation – get more fibre into your diet such as fresh fruit, vegetables and cereals. Try to drink several glasses of water or squash every day. If you can, it may also help to increase your level of exercise.
feeling dizzy – this is probably due to low blood pressure. Drink plenty of water or squash. Do not stand up too quickly after you've been sitting or lying down. Do not drive, cycle or use tools or machinery until this feeling passes. It's best not to drink alcohol until you see how the medicine affects you.
dry mouth – chew sugar-free gum or have some sugar-free sweets.
feeling sleepy – take nortriptyline in the evening. It's best not to drink alcohol until you see how the medicine affects you. Do not drive, cycle or use tools or machinery while you're feeling sleepy.
difficulty peeing – try to relax when you pee. Do not try to force the flow of urine. If it does not happen, try again later. Talk to your doctor urgently if you cannot pee at all.
headaches – make sure you rest and drink plenty of fluids. It's best not to drink alcohol until you see how the medicine affects you. Try taking paracetamol or ibuprofen if you need pain relief. Talk to your doctor if the headaches last longer than a few days or are severe.

7. Pregnancy and breastfeeding

Nortriptyline and pregnancy

You may be advised to continue taking nortriptyline during pregnancy, especially if you take it to treat depression.

Speak to your doctor if you become pregnant while taking nortriptyline. Do not stop taking your medicine unless your doctor tells you to.

Your doctor can explain the risks and benefits of taking nortriptyline and will help you choose the best treatment for you and your baby.

Nortriptyline and breastfeeding

If your doctor or health visitor says your baby is healthy, you can use nortriptyline while breastfeeding.

Notriptyline passes into breast milk in very small amounts so it's unlikely to cause any harm to your baby.

If you are being treated for depression it's important to continue taking nortriptyline to keep you well. Breastfeeding will also benefit both you and your baby.

If you notice that your baby is not feeding as well as usual, or seems unusually sleepy, or if you have any other concerns about your baby, then talk to your health visitor or doctor as soon as possible.

Non-urgent advice: Tell your doctor if you're:

trying to get pregnant
pregnant
breastfeeding

For more information about how nortriptyline can affect you and your baby during pregnancy, read this leaflet on the Best Use of Medicines in Pregnancy (BUMPs) website.

8. Cautions with other medicines

Many medicines taken with nortriptyline can affect each other and increase the chance of side effects.

Always check with your doctor or a pharmacist before starting any new medicine while you are taking nortriptyline.

Taking opioid-based medicines, like codeine, morphine or oxycodone, together with nortriptyline can increase your risk of becoming very drowsy and having breathing problems.

Tell your doctor if you have ever taken any medicines for depression. Some antidepressants can affect the way nortriptyline works and cause very high blood pressure. This can happen even after you have stopped taking them.

Mixing nortriptyline with herbal remedies and supplements

Do not take St John's wort, the herbal remedy for depression, while you are being treated with nortriptyline. It will increase your risk of side effects.

There's very little information about taking nortriptyline with other herbal remedies and supplements. They are not tested in the same way as medicines.

Important: Medicine safety

Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements.

9. Common questions about nortriptyline

How does nortriptyline work?

Nortriptyline is from a group of antidepressants called tricyclic antidepressants.

If you're taking it for pain relief, it will change the way that your nerves receive pain signals so your pain goes away.

If you're taking nortriptyline for depression, it's thought to work by increasing a chemical called serotonin in the brain. This helps to improve your mood.

How long does it take to work?

If you take nortriptyline to treat nerve pain, it usually takes a week or so for pain to begin to wear off. You may start to sleep better at night.

If you take nortriptyline for depression, you may start to feel better after a couple of weeks. It can take 4 to 6 weeks until you feel the full benefits.

Do not stop taking nortriptyline after 1 to 2 weeks just because you feel it's not helping your symptoms. Give it at least 6 weeks to work.

How will nortriptyline make me feel?

Although nortriptyline is an antidepressant, the doses are lower if you take it to help pain. Taking nortriptyline as a painkiller will not change your personality or make you feel any different.

If you're taking nortriptyline for depression, it helps to lift your mood gradually so you feel better. You may get on with people more easily because you are less anxious.

Nortriptyline will not change your personality or give you a high of feeling happy. It will simply help you feel like yourself again.

Do not expect to feel better overnight though. Some people feel worse during the first few weeks of treatment before they begin to feel better.

What if I do not feel better?

When nortriptyline is taken for nerve pain, most people are able to sleep better within a few days and the pain starts to wear off after a week or so.

If your pain does not get better or you have side effects, talk to your doctor as there may be other treatments which work for you.

Talk to your doctor if you take nortriptyline for depression and you do not feel better after taking it for 6 weeks, or the side effects bother you.

How long will I take nortriptyline for?

If you take nortriptyline for pain, once your pain is under control, you'll probably continue to take it for as long as it's working for you. Some people take it for many months and even for years.

If you take nortriptyline for depression, it's likely you'll take it for several more months once you're feeling better.

Most doctors recommend that you take antidepressants for 6 months to a year after you've stopped feeling depressed.

Stopping before then can make depression come back. Talk to your doctor about the risks and benefits of continuing to take nortriptyline for more than a few months.

Can I take nortriptyline long term?

For most people, nortriptyline is safe to take for a long time.

There do not seem to be any lasting harmful effects from taking nortriptyline for many months or years.

Is nortriptyline addictive?

Nortriptyline is not addictive but you can get withdrawal side effects if you stop taking it suddenly. You may have flu-like symptoms like feeling sick, muscle pain and feeling tired or restless.

To help prevent this happening, your doctor will probably recommend reducing your dose gradually over several weeks, or longer if you have been taking nortriptyline for a long time.

What will happen when I stop taking it?

You may get withdrawal side effects when you stop taking nortriptyline, especially if you stop taking it suddenly.

These side effects are a physical reaction as the medicine leaves your body. They can include sweating, being sick, feeling anxious, and difficulty falling asleep.

To help prevent them, your doctor will probably recommend reducing your dose gradually over several weeks, or longer if you have been taking nortriptyline for a long time.

Important

Do not stop taking nortriptyline suddenly, or without talking to your doctor.

Can I take nortriptyline with other painkillers?

Paracetamol and ibuprofen are safe to take with nortriptyline for a short time. Talk to your doctor if you need to take them for more than a few days.

Will it affect my sex life?

A few people have sex-related problems while they take nortriptyline. Both men and women may have changes in their sex drive.

Sexual side effects are not very common and should pass after the first couple of weeks. If they do not, and this is a problem for you, go back to your doctor to see if there's another medicine you can try.

How is nortriptyline different to other medicines for nerve pain?

Nortriptyline is usually prescribed by your doctor if other painkillers, such as paracetamol and ibuprofen, have not worked.

Nortriptyline does not work any better or worse than other medicines for nerve pain.

How is it different to other antidepressants?

Nortriptyline does not work any better or worse than other antidepressants. However, sometimes people respond better to one antidepressant than another.

The best antidepressant for you depends on your symptoms and what medicines have worked for you in the past.

Talk to your doctor if you are not feeling any better after taking nortriptyline for 6 weeks or if the side effects still bother you.

Will I gain or lose weight?

Nortriptyline can change how hungry you feel. Some people feel more hungry when they're taking it, and others feel less hungry. So your weight may change when you first start taking it.

If you start to have problems with your weight while taking nortriptyline, talk to your doctor or pharmacist.

Can I drink alcohol with it?

You can drink alcohol while taking nortriptyline but it may make you feel sleepy. It might be best to stop drinking alcohol until you see how the medicine makes you feel.

Are there foods and drinks I should avoid?

Apart from being extra careful with alcohol, you can eat and drink normally while taking nortriptyline.

Will it affect my contraception?

Nortriptyline does not affect any type of contraception including the combined pill and emergency contraception.

Will it affect my fertility?

There's no clear evidence to suggest that nortriptyline affects fertility in either men or women.

However, speak to your doctor or a pharmacist before taking nortriptyline if you're trying to get pregnant.

Can I drive or ride a bike?

Some people feel sleepy while they're taking nortriptyline. It's best to stop driving, cycling or operating machinery for the first few days and after each dose increase, until you know how this medicine makes you feel.

Will recreational drugs affect nortriptyline?

Cannabis with nortriptyline can make you feel very sleepy, especially if you've just started taking it. Cannabis can also give you a fast heartbeat.

It may be dangerous to take nortriptyline with:

methadone
stimulants like MDMA (ecstasy) or cocaine
hallucinogens like LSD
novel psychoactive substances (these used to be called "legal highs") like mephedrone

Nortriptyline has not been properly tested with recreational drugs. Talk to your doctor if you think you might use recreational drugs while taking nortriptyline.

usage, dosage and side effects

What is nortriptyline used for?

Treating depression in adults. Nortriptyline is not licensed for treating depression in children and adolescents under 18 years of age. However, some specialists may still prescribe it if they feel it is essential.
Treating nerve pain (neuralgia or neuropathic pain) in adults, for example caused by nerve damage as a result of diabetes, stroke, injuries, chemotherapy, amputation (phantom limb limb) or shingles (postherpetic neuralgia). This is an unlicensed use of nortriptyline.

How does nortriptyline work?

Nortriptyline hydrochloride is a type of medicine called a tricyclic antidepressant (TCA). It works by enhancing the activity of the neurotransmitters serotonin and noradrenaline in the brain.

Neurotransmitters are natural body chemicals that act as chemical messengers between the nerve cells. Serotonin and noradrenaline are neurotransmitters known to be involved in regulating emotions, mood and behaviour, among other things. In depressive illness less serotonin and noradrenaline than normal is released from nerve cells in the brain.

Nortriptyline works by stopping the serotonin and noradrenaline that has been released from being reabsorbed back into the nerve cells in the brain. This helps to prolong their effects and over time this helps to lighten mood and relieve depression.

Nortriptyline won't change your personality or make you feel instantly happy and relaxed. It works over time to correct the chemical changes in your brain that have made you become depressed, and helps you get back to feeling like your old self.

It's not fully understood how nortriptyline relieves nerve pain. It's thought to work by enhancing the nerve signals within the central nervous system that naturally reduce pain messages arriving in the brain.

How long does nortriptyline take to work?

In depression it may take between two to four weeks before nortriptyline starts to work and you begin to feel better, so it's very important that you keep taking it, even if it doesn't seem to make much difference at first. You'll usually need to keep taking nortriptyline every day for several months, and for at least six months after you feel better. You should keep taking it for as long as your doctor asks you to. If you feel your depression has got worse, or if you have any distressing thoughts, or feelings about suicide or harming yourself in these first few weeks, or indeed at any point during treatment or after stopping treatment, then it is very important to talk to your doctor.
With nerve pain nortriptyline may start to help in a few days for some people, while others don't see much difference for two three to weeks. It can take several weeks for you to see the maximum benefit of this medicine, so it's important to persevere with taking it. You should then keep taking it for as long as your doctor recommends.

How do I take nortriptyline?

Always follow the instructions given by your doctor regarding the nortriptyline dose you should take. Remember that it takes a while for nortriptyline to start working, so keep taking it as prescribed even if it doesn't seem to make much difference at first. Do not take more than the dose prescribed by your doctor.
Nortriptyline is usually taken three or four times a day, although it can also be prescribed as a single dose to be taken at bedtime. Follow the instructions given by your doctor. Try to always take your doses at the same times each day - this will help you to remember to take them.
Nortriptyline tablets can be taken either with or without food, on a full or empty stomach.
If you forget to take a dose at your usual time take it as soon as you remember, unless it's nearly time for your next dose. In this case just leave out the missed dose and take your next dose as usual when it is due. Do not take a double dose to make up for a missed dose.
You should keep taking nortriptyline regularly until your doctor tells you to stop. When treating depression, current recommendations are that antidepressants are continued for at least six months after recovery to help prevent the depression coming back after the medicine is stopped.
Nortriptyline is not addictive. However, do not suddenly stop taking nortriptyline, because this can cause withdrawal symptoms such as feeling sick, shivering, headache, difficulty sleeping, sweating, irritability, restlessness or anxiety. Withdrawal symptoms are temporary and are not due to dependence on the medicine. They can usually be avoided by stopping nortriptyline gradually, usually over a period of weeks or months, depending on your individual situation. Follow the instructions given by your doctor when it's time to stop treatment.

What should I know about taking nortriptyline?

Nortriptyline may cause drowsiness, dizziness, problems concentrating and blurred vision and could reduce your ability to drive or operate machinery safely. Do not drive or operate machinery if affected.
Nortriptyline can sometimes make you feel dizzy or unsteady when you get up from lying down or sitting, especially when you first start taking the medicine. To avoid this try getting up slowly. If you do feel dizzy, sit or lie down until the symptoms pass.
Nortriptyline can cause a dry mouth, which may increase the risk of tooth decay if you take nortriptyline for long periods of time. It's important to practice good oral hygiene and visit your dentist regularly for check-ups.
Nortriptyline may make your skin more sensitive to sunlight than usual. Don't use sunbeds or sunlamps and avoid exposing your skin to excessive amounts of strong sunlight until you know how it affects you.
If you need to have any surgery make sure you let the anaesthetist know that you are taking nortriptyline.

Can I drink alcohol with nortriptyline?

You should avoid drinking alcohol while taking nortriptyline because it will make you more likely to feel sleepy, dizzy or confused, or to have blurred vision. This effect is likely to be worse if you drink alcohol when you start treatment or after any dose increases.

Who shouldn't take nortriptyline?

People with severe liver disease.
People with an irregular heartbeat (arrhythmia), heart block, or who have recently had a heart attack.
People in a manic phase of bipolar disorder (manic depression).
People who have taken a monoamine oxidase inhibitor antidepressant (MAOI) in the last two weeks.
People who are allergic or intolerant to any ingredient of the medicine. Check the ingredients listed in the leaflet that comes with the medicine if you know you have specific allergies or intolerances.

Who might need a lower nortriptyline dose or extra monitoring?

Elderly people.
People with liver problems.
People with heart disease or high blood pressure.
People with an overactive thyroid gland (hyperthyroidism).
People with a tumour of the adrenal gland (phaeochromocytoma).
People with chronic constipation.
People who have difficulty passing urine, such as men with an enlarged prostate gland.
People with raised pressure in the eye or glaucoma.
People with diabetes.
People who suffer from epilepsy or are at risk of having seizures (fits), eg due to alcohol/drug withdrawal, brain damage, or other medicines.
People receiving electroconvulsive therapy (ECT).
People with psychotic illness, eg schizophrenia.
People with a history of bipolar affective disorder (manic depression). This medicine should be stopped in people entering a manic phase.
If your child is prescribed nortriptyline it is very important that they are encouraged to report any distressing feelings, thoughts about suicide or self-harm, irritability, aggressive behaviour, mood changes or other unusual change in behaviour that they may experience while taking the medicine. If you notice a change in your child's behaviour, or are worried about them at any point, it is important to talk to your doctor immediately.

Can I take nortriptyline while pregnant or breastfeeding?

It is important to get medical advice from your doctor if you think you could be pregnant or want to plan a pregnancy while taking nortriptyline. Nortriptyline should preferably not be used during pregnancy, particularly in the first and third trimesters, because its safety has not been fully established. However, it's important to talk to your doctor about the risks and benefits of taking the medicine compared with stopping treatment or using other treatments. For example, if nortriptyline is taken during the third trimester it could cause side effects or withdrawal symptoms in the baby after birth, and the baby may need extra monitoring because of this.
If you get pregnant and decide to stop taking nortriptyline, don't do this suddenly. Your doctor will give you instructions on how to stop treatment gradually to avoid getting withdrawal symptoms.
Get advice from your doctor if you want to breastfeed while you're taking nortriptyline. Nortriptyline passes into breast milk, but only in very small amounts that are unlikely to be harmful to a nursing infant. If you're taking nortriptyline it's usually fine for you to breastfeed providing your baby is healthy, wasn't born prematurely, and is monitored for potential problems such as drowsiness. However, do always check with your doctor first, because various factors need to be taken into account.

What are the possible side effects of nortriptyline?

Medicines and their possible side effects can affect individual people in different ways. The following are some of the side effects known to be associated with nortriptyline. Just because a side effect is stated here doesn't mean that all people taking this antidepressant will experience that or any side effect. Many people find that if they do get side effects these tend to get better over time, so it's worth persevering with treatment.

Very common (affect more than 1 in 10 people)

Dry mouth.
Blurred vision.
Constipation.
Feeling sick.
Dizziness, particularly when getting up.
Headache.
Tremor.
Fast heartbeat or palpitations.
Flushing or sweating.

Common (affect between 1 in 10 and 1 in 100 people)

Feeling weak or tired.
Confusion or problems concentrating.
Pins and needles sensations.
Involuntary muscle movements such as twitching.
Sexual problems, such as reduced sex drive or erectile dysfunction.
Change in the way things taste.
Weight gain.

Rare or unknown frequency

Drowsiness.
Difficulty passing urine.
Hair loss.
Breast enlargement, production of breast milk.
Irregular heartbeats (arrhythmias).
Reduced numbers of red blood cells, white blood cells or platelets in the blood. Tell your doctor if you experience a sore throat, high temperature (fever) or unusual bruising or bleeding while taking nortriptyline, because these could be a sign of a problem with your blood cells.
Convulsions (fits or seizures).
Liver problems, such as liver inflammation (hepatitis) or jaundice.
Drop in the amount of sodium in the blood - a condition called hyponatraemia. This can cause symptoms such as drowsiness, confusion, muscle twitching or convulsions. Elderly people may be particularly susceptible to this effect. You should consult your doctor if you develop any of these symptoms while taking this medicine so that your blood sodium level can be checked if necessary.

Read the leaflet that comes with the medicine or talk to your doctor or pharmacist if you want any more information about the possible side effects of nortriptyline. If you think you have experienced a side effect, did you know you can report this using the yellow card website?

Can I take other medicines with nortriptyline?

It's important to tell your doctor or pharmacist if you're already taking any medicines, including those bought without a prescription and herbal medicines, before you start treatment with nortriptyline.

Can I take over-the-counter medicines with nortriptyline?

You should always check with your pharmacist before taking any new medicines once you've started taking nortriptyline, to make sure that the combination is safe for you. However these are the main things to be aware of:

If you need to take a painkiller it's fine to take paracetamol, aspirin or ibuprofen with nortriptyline, assuming these are appropriate for you. If you find nortriptyline makes you drowsy or constipated, it's best to avoid taking co-codamol, because this painkiller could make these problems worse.

You shouldn't take cold and flu remedies that contain a decongestant such as pseudoephedrine or phenylephrine while you're taking nortriptyline.

Avoid taking excessive amounts of stimulant laxatives like senna or bisacodyl while you're taking nortriptyline. If you need to treat constipation ask your pharmacist for advice.

If you need an antihistamine it's best to avoid those that can make you sleepy, like chlorphenamine, diphenhydramine and promethazine - go for a non-sedating one like cetirizine or loratadine instead.

Don't take the herbal remedy St John's wort (Hypericum perforatum) with nortriptyline.

What about prescribed medicines?

You're more likely to feel sleepy on nortriptyline if you also take other medicines that can cause drowsiness, such as the following:

antipsychotics, eg haloperidol
barbiturates, eg phenobarbital, amobarbital (these may also make the antidepressant less effective)
benzodiazepines, eg diazepam, temazepam
sedating antihistamines, eg promethazine, hydroxyzine
sleeping tablets, eg zopiclone
strong opioid painkillers, such as morphine, codeine, tramadol, fentanyl
other tricyclic antidepressants, eg amitriptyline.

You may be more likely to feel dizzy or faint if you take nortriptyline alongside medicines that lower blood pressure, including medicines used to treat high blood pressure and medicines that can lower blood pressure as a side effect, for example benzodiazepines. If you're taking medicines that lower blood pressure, tell your doctor if you feel dizzy or faint after starting treatment with nortriptyline, as your doses may need adjusting.

You may be more likely to get a dry mouth, constipation, difficulty passing urine or blurred vision if you take medicines that have anticholinergic effects with nortriptyline. These include the following:

anticholinergics for urinary incontinence, eg tolterodine, oxybutynin
anticholinergics for Parkinson's symptoms, eg procyclidine, trihexyphenidyl
some antihistamines, eg promethazine, chlorphenamine
antispasmodics, eg hyoscine, atropine
some antipsychotics, eg chlorpromazine, clozapine
certain other antidepressants
some antisickness medicines, eg meclozine, cyclizine.

If you take other medicines or drugs that enhance serotonin activity in the brain while you're taking nortriptyline, you may be more likely to get a side effect called the 'serotonin syndrome', with symptoms such as agitation, tremor, shivering, increased heart rate and diarrhoea. Other medicines that increase serotonin activity include the following:

dapoxetine
dexamfetamine
fentanyl
illegal drugs such as cocaine, amphetamine (speed) and ecstasy (MDMA)
lithium
linezolid
methadone
selegiline, rasagiline or safinamide for Parkinson's
SSRI, tricyclic or related antidepressants, eg paroxetine, citalopram, amitriptyline, duloxetine, venlafaxine
tramadol
triptans for migraine, eg sumatriptan
tryptophan.

Nortriptyline may alter the anti-blood-clotting effect of coumarin anticoagulant medicines such as warfarin. Your doctor may want to check your blood clotting time (INR) more frequently if you are taking these two medicines together.

The following medicines may increase the blood level of nortriptyline and could increase the risk of its side effects:

bupropion
cimetidine
fluconazole
methylphenidate
protease inhibitors for HIV such as ritonavir
quinidine
SSRI antidepressants such as fluvoxamine and fluoxetine
terbinafine.

If you get a dry mouth while taking nortriptyline you may find that medicines that are designed to dissolve and be absorbed from under the tongue, eg sublingual glyceryl trinitrate (GTN) tablets for angina, become less effective. This is because the tablets do not dissolve properly in a dry mouth. To resolve this, drink a mouthful of water before taking sublingual tablets.

The following medicines should preferably not be used with nortriptyline, because they might increase the risk of developing an abnormal heart rhythm:

medicines to treat abnormal heart rhythms (anti-arrhythmics), eg amiodarone, procainamide, quinidine, disopyramide, dronedarone
certain antimalarials, eg quinine, halofantrine, Riamet, mefloquine
certain antimicrobials, eg erythromycin given by injection, clarithromycin, moxifloxacin, voriconazole or pentamidine
certain antipsychotics, eg amisulpride, thioridazine, chlorpromazine, sertindole, haloperidol, pimozide, zuclopenthixol, sulpiride
certain other antidepressants, eg citalopram, escitalopram
arsenic trioxide
domperidone
droperidol
fingolimod
hydroxyzine
methadone
mizolastine
ondansetron
ranolazine
saquinavir
sildenafil
tolterodine
vardenafil.

The medicines listed below can sometimes cause the amount of potassium in the blood to drop too low. If this happens in someone taking nortriptyline it could increase the risk of irregular heartbeats. Your doctor may want to check your potassium levels regularly if you are taking one of these medicines with nortriptyline:

beta-2-agonists for asthma, eg salbutamol
corticosteroids by mouth or injection, such as prednisolone
diuretics such as furosemide, bendroflumethiazide, acetazolamide
intravenous amphotericin
stimulant laxatives, eg senna
theophylline.

Nortriptyline should not be taken with a monoamine oxidase inhibitor antidepressant (MAOI), eg phenelzine, tranylcypromine, isocarboxazid, or moclobemide. Treatment with nortriptyline should not be started until at least two weeks after stopping an MAOI and vice versa.

Last updated 25.04.2018

Helen Marshall, BPharm, MRPharmS Helen Marshall, BPharm, MRPharmS A UK registered pharmacist with a background in hospital pharmacy.

Memorial Sloan Kettering Cancer Center

Adult Medication

Provided by Lexicomp ^® , this document contains all the information you need to know about this medicine, including indications, directions for use, side effects, and when your healthcare provider should be contacted.

Trade names: USA

Pamelor

Trade names: Canada

APO-Northriptyline; Aventyl; TEVA-Nortriptyline [DSC]

Warning

Drugs like this have increased the likelihood of suicidal thoughts or actions in children and young people. This risk may be higher in people who have tried or had suicidal thoughts in the past. All people taking this drug must be closely monitored. If you develop or worsen disorders such as depression, nervousness, anxiety, grouchiness, panic attacks, and changes in mood or behavior, contact your doctor immediately. Contact your doctor immediately if you have suicidal thoughts or suicide attempts. nine0006
This drug is not approved for use in children. Consult your doctor.

What is this drug used for?

Used to treat depression.
This drug may be used for other indications. Consult your doctor.

What should I tell my doctor BEFORE taking this drug?

If you have an allergy to this drug, any of its ingredients, other drugs, foods, or substances. Tell your doctor about your allergies and how they have manifested. nine0006
If you have recently had a heart attack.
If you have a certain heart disorder called Brugada syndrome or have ever fainted for no reason.
If you are taking any of the following: linezolid or methylene blue.
If you have taken medicines for depression or Parkinson's disease in the past 14 days. These include isocarboxazid, phenelzine, tranylcypromine, selegiline, or rasagiline. An episode of very high blood pressure may occur. nine0006

This list of drugs and conditions that may interact with this drug is not exhaustive.

Tell your doctor and pharmacist about all medicines you take (prescription and over-the-counter, natural products and vitamins) and any health problems you have. You need to make sure that this drug is safe for your conditions and in combination with other drugs you are already taking. Do not start or stop taking any drug or change the dosage without your doctor's advice. nine0003

What do I need to know or do while taking this drug?

Tell all your healthcare providers that you are taking this drug. These are doctors, nurses, pharmacists and dentists. You may need to stop taking this drug before certain types of surgery, as told by your doctor. If you stop taking this drug, your doctor will tell you when you can start taking this drug again after your surgery or procedure. nine0006
Avoid driving and other demanding activities until you see how this drug affects you.
To reduce the risk of dizziness or loss of consciousness, rise slowly from a lying or sitting position. Walking up and down stairs should be done with care.
If you have high blood sugar (diabetes), check your blood sugar regularly.
Talk to your doctor if you have signs of high or low blood sugar such as fruity breath, dizziness, rapid breathing, tachycardia, confusion, drowsiness, feeling weak, flushing, headache, unusual thirst or hunger , frequent urination, tremors or sweating. nine0006
Talk to your doctor before using alcohol, marijuana or other forms of cannabis, or prescription or over-the-counter drugs that can slow you down.
If you have or have ever had seizures, talk to your doctor.
You can get burned quickly. Avoid direct sunlight, sun lamps and tanning beds. Use sun umbrellas, wear long clothes and sunglasses. nine0006
Caution should be exercised in hot weather and during vigorous activity. Drink plenty of fluids to prevent dehydration.
There may be an increased risk of eye problems when using this drug in some patients. Your doctor may order an eye examination to see if you are at increased risk for these eye problems. Call your doctor right away if you have eye pain, vision changes, swelling or redness around the eye. nine0006
Some people who take this drug have a certain heart disorder (Brugada syndrome). These people had the disorder before but were unaware of it. People with Brugada syndrome have abnormal heart rhythms and are at risk of sudden death. Consult your doctor.
A severe and sometimes fatal complication called serotonin syndrome can occur. This risk may be increased if certain other drugs are taken at the same time. Call your doctor right away if you experience agitation, balance problems, confusion, hallucinations, high fever, tachycardia or abnormal heart rhythms, flushing, muscle twitching or stiffness, seizures, tremors or tremors, excessive sweating, severe diarrhea, nausea or vomiting , a very severe headache. nine0006
If you are 65 years of age or older, use this drug with caution. You may experience more side effects.
Tell your doctor if you are pregnant, plan to become pregnant, or are breastfeeding. The benefits and risks for you and your child will need to be discussed.

What side effects should I report to my doctor immediately?

WARNING. In rare cases, this drug can cause serious and sometimes deadly side effects in some patients. Call your doctor right away or get medical help if you have any of the following signs or symptoms that could be associated with serious side effects:

Signs of an allergic reaction such as rash, hives, itching, red and swollen skin with blisters or peeling, possibly associated with fever, wheezing or wheezing, chest or throat tightness, difficulty breathing, swallowing or speaking, unusual hoarseness , swelling in the mouth, face, lips, tongue or throat.
Signs of high or low blood pressure, such as very severe headache or dizziness, fainting, or changes in vision. nine0006
Pain or pressure in the chest.
Increased or abnormal heart rhythm.
Weakness on 1 side of the body, difficulty speaking or thinking, problems with balance, sagging on one side of the face, or blurred vision.
Confusion of consciousness.
Hallucinations (a person sees or hears something that is not in reality).
Nightmares.
Unusual sensations of burning, numbness or tingling.
Trembling.
For problems with body control. nine0006
Ringing in the ears.
Severe constipation or abdominal pain. These may be signs of a severe bowel disorder.
Obstruction of the urinary tract.
Convulsions.
Fever, chills, sore throat; the appearance of bruising and bleeding for unexplained reasons; pronounced feeling of tiredness or weakness.
Yellowness of the skin or eyes.
Irritation or pain in the mouth.
Changing the color of the tongue.
Hair loss.
Enlarged breasts.
Discharge from the nipple.
Change in sexual desire.
Inability to achieve or maintain an erection.
Swelling of the testicles.

What are some other side effects of this drug?

Any medicine can have side effects. However, for many people, side effects are either minor or non-existent. Talk to your doctor or get medical help if these or any other side effects bother you or don't go away:

Dry mouth.
Feeling dizzy, drowsy, tired or weak.
Constipation, diarrhoea, abdominal pain, nausea, vomiting or loss of appetite.
Headache.
Change in the ability to perceive taste.
Gastric colic.
Sleep disorders.
Weight gain or loss.
Excessive sweating.
Hyperemia (blush).

This list of possible side effects is not exhaustive. If you have any questions about side effects, please contact your doctor. Talk to your doctor about side effects. nine0003

You can report side effects to the National Health Board.

You can report side effects to the FDA at 1-800-332-1088. You can also report side effects at https://www.fda.gov/medwatch.

What is the best way to take this drug?

Use this drug as directed by your doctor. Read all the information provided to you. Strictly follow all instructions.

All editions:

Once daily, take this medication 30 minutes before bed.
Keep taking this drug as your doctor or other health care professional tells you to, even if you feel well.
Do not stop this drug abruptly without talking to your doctor. This can increase the risk of side effects. If necessary, taking this drug should be stopped gradually, in accordance with the recommendations of the doctor. nine0006

Fluid:

Care should be taken when measuring liquid doses. Use the dispenser that comes with the medicine. If the dispenser is not provided in the package, ask the pharmacist for a dosing agent for this drug.

What if I miss a dose of a drug?

Take the missed dose as soon as you can.
If it is time for your next dose, do not take the missed dose and then return to your regular dosing schedule. nine0006
Do not take 2 doses or an additional dose at the same time.
If you are taking 1 daily dose at bedtime, do not take the missed dose the next morning.

How do I store and/or discard this drug?

Store at room temperature.
Store in a dry place. Do not store in the bathroom.
Keep all medicines in a safe place. Keep all medicines out of the reach of children and pets. nine0006
Dispose of unused or expired drugs. Do not empty into a toilet or sewer unless instructed to do so. If you have any questions about disposing of medicines, ask your pharmacist. Drug disposal programs may be in place in your area.

General information about drugs

If your health does not improve or even worsens, call your doctor. nine0006
Do not give your medicine to anyone or take other people's medicine.
Some medicines may come with other patient information sheets. If you have questions about this drug, talk with your doctor, nurse, pharmacist, or other health care professional.
A separate patient leaflet is included with this product. Please read this information carefully. Reread it each time you refill your supply. If you have any questions about this drug, ask your doctor, pharmacist, or other health care professional. nine0006
If you think you have overdosed, call a poison control center or get medical help right away. Be prepared to tell or show what drug you took, how much, and when it happened.

Consumer Use of Information and Limitation of Liability

This summary information includes a summary of the diagnosis, treatment, and/or drug product. It is not intended to be a comprehensive source of data and should be used as a tool to help the user understand and/or evaluate potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a particular patient. It should not be considered medical advice or a substitute for medical advice, diagnosis or treatment provided by a physician based on a medical examination and assessment of the patient's specific and unique circumstances. Patients should consult with their physician for full information about their health, medical issues, and treatment options, including any risks or benefits regarding the use of medications. This information is not a guarantee that a treatment or drug is safe, effective, or approved for a particular patient. UpToDate, Inc. and its subsidiaries disclaim any warranties or liabilities related to this information or its use. The use of this information is subject to the Terms of Use found at https://www.wolterskluwer.com/en/know/clinical-effectiveness-terms. nine0003

Copyright

Migraine treatment - Clinic Zdorovye 365 Yekaterinburg

Doctors say that many women don't talk about how badly their head hurts because they don't want to complain too much. One of the problems may be that people suffering from migraines think that nothing will help them. They have watched their mother or grandmother suffer from a migraine and think they should suffer too. Despite significant advances in pharmacology and the large number of treatment options that are available today, many continue to take the ineffective drugs that their older relatives used to combat migraine pain. nine0003

Typically, migraine patients take some kind of pain medication, lie in bed, try to overcome nausea and vomiting, and protect themselves from lights, sounds, and smells that can trigger or exacerbate a migraine attack.

Unfortunately, many migraine sufferers do not see a doctor, despite the fact that today there are many effective treatments.

If you have migraine attacks, it is important to build a good relationship with your doctor because migraine is a recurring disease. The first step is to find a doctor with experience in migraine treatment who understands that migraine is a disease that occurs due to changes at the biological level. nine0003

We recommend that you find a doctor who is willing to consider several treatment options, including prescription and over-the-counter medications and lifestyle changes.

During treatment, communication can be poorly tolerated by patients for a number of reasons, but it is the key to effective treatment. About half of migraine patients have stopped looking for a way to deal with their headaches, in part because they were not satisfied with the treatment, a statistic that can be improved by patient-physician communication. nine0003

Communication and treatment counselors can provide advice on how to start a dialogue with a doctor, discuss symptoms and treatment options. Many people believe that if you mark a calendar when attacks occur, you can learn how to control headaches. This method is especially effective when you and your doctor begin to draw up a treatment program.

In the headache calendar, note:

when headaches occur
possible pathogens, including diet, stress, environment, etc.
dates of menstruation
remedies that did not help with pain

The National Headache Foundation of America website www.headaches.org also provides a wealth of useful information for people with headaches, including a headache diary:

treatment and then evaluate the treatment you are currently receiving. Rate how satisfied you are with the chosen treatment program (from "completely satisfied" and ending with "extremely dissatisfied" with intermediate ratings). Rate the treatment according to the following criteria:

fast acting
causes the fewest side effects
non-sedating
reduces sensitivity to bright lights and/or sounds
easy to use
relieves headache
only needs to be taken once a week
exists in the form of injections
is available as a nasal spray
is available as 9 tablets0006
is proven effective
available in various shapes

Also rank these criteria according to how important they are to you. Use the description (from "very important" to "not important") to help you prioritize and tailor a treatment program that's right for you.

Next, make a list of activities that you think you have to neglect because of a migraine. Be sure to include work, relationships with family members, personal time, sleep, sports, social status, or other activities that have to be relegated to the background due to migraine attacks. nine0003

In fact, if you write down what you have to give up because of a migraine and discuss it with your doctor, then the doctor will be able to choose the most comprehensive course of treatment. Most often, doctors select a more effective method of treatment if they receive detailed information about the symptoms.

Unfortunately, often during consultations little attention is paid to activities that have to be abandoned because of a headache. In order to get more information about such activities, there is, for example, a questionnaire that estimates the number of activities that have to be abandoned due to migraine. nine0003

Then make an appointment with the doctor to discuss your specific case. Take your lists with you. Ask for a course of treatment that takes into account the factors that seem most important to you in managing your headache and are consistent with your lifestyle. Before leaving the doctor's office, make an appointment to discuss the effectiveness or failure of the chosen treatment option.

Finally, after starting treatment, write down in a diary the frequency and severity of headaches, and how the treatment affects you. At your next visit, show your doctor your notes and, if necessary, ask for changes to your treatment. Finding the right treatment for you takes patience and adjustments. nine0003

Medication

The doctor makes a treatment plan based on how often headaches occur. Rare headaches (once or twice a month) are usually treated with fast-acting, strong medications that reduce headache, nausea, and increased sensitivity to bright lights and/or sounds. Women with migraine often have to change the type of treatment. They are recommended preventive treatment.

If you have frequent or prolonged headaches, or if you have pain that interferes with your daily activities, you will need to take medication daily to prevent migraines. nine0003

Medicines to treat or shorten migraine

One of the most commonly used drug classes is the triptans. Scientists aren't sure exactly how they work, but these drugs reduce migraine headaches and ease the aura. Specialized triptans include naratriptan (Amerge by Amerge), rizatriptan (Maxalt by Maxalt), sumatriptan (Imitrex by Imitrex), zolmitriptan (Zomig by Zomig), almotriptan (Axert, Axert), frovatriptan (Frova). , Frova) and eletriptan (Relpax by Relpax). All triptans listed are available in tablet form. "Imitrex" and "Zomig" are also produced in the form of a nasal spray, and "Imitrex" in the form of injections. The fastest and most effective drugs in the form of injections. nine0003

Listed below are drugs used for emergency management of severe migraine pain :

dihydroergotamine (Migrenol Migrainol, DHE 45)
ergotamine, a drug that was commonly prescribed for the treatment of migraine before the advent of triptans. Ergotamine is a more economical, but at the same time, less effective option. Ergotamine is usually given to people with long-lasting (more than 48 hours) or frequent migraines.
opioids, namely codeine
corticosteroids, including hydrocortisone and dexamethasone

Since ergotamine and dihydroergotamine (DHE 45) can cause nausea and vomiting, they can be combined with antinausea drugs. Experts warn that ergotamine should not be taken in excessive doses by people with angina, severe hypertension, or vascular, liver, or kidney disease. The same goes for DHE. Also, this drug is not recommended for pregnant women. nine0003

Medicines to treat/prevent frequent migraine attacks :

Beta-blockers prevent vasodilation. These include propranolol (Inderal Inderal), atenolol (Tenormin Tenormin), metoprolol (Lopressor Lopressor), nadolol (Corgard Corgard), and timolol (Blocarden Blocadren). Caution: Doctors recommend that people taking beta-blockers, and especially those with a family history of heart disease, do not stop taking these drugs abruptly. nine0006
Calcium channel blockers prevent migraine in susceptible individuals. Common calcium channel blockers include: verapamil (Calan Calan, Isoptin Isoptin), nifedipine (Procardia Procardia, Adalat Adalat) and nimodipine (Nimotop Nimotop).
Anticonvulsants. Some drugs prevent seizures, such as divalprex sodium (Depakote, Depakote), valproate (Depacon, Depacon), and topiramate (Topamax, Topamax). Some people experience migraines less often as a result of taking these medications. In large doses, they can cause side effects such as nausea, vomiting, diarrhea, hair loss, and dizziness. nine0006
Antidepressants. In some cases, antidepressants are used to prevent migraines. These include tricyclic antidepressants, such as amitriptyline (Elavil by Elavil, Endep by Endep), nortriptyline (Pamelor by Pamelor, Aventyl by Aventyl), and protriptyline (Vivaktil by Vivactil).
Monoclonal antibody drugs, such as Ajovy (fremanezumab) - a drug for the prevention (reduction in the number of attacks) of episodic and chronic migraine. The more calcitonin-related peptide (CGRP) is released in migraine, the stronger and more painful the headache. Ajovi binds the CGRP neuropeptide or its receptor and blocks the migraine headache pathway. nine0006

Atypical antidepressants, such as venlafaxine (Effexor) and mirtazapine (Remeron, Remeron) can help by removing certain chemicals from the brain, such as serotonin, norepinephrine, and dopamine.

Warning: The US Food and Drug Administration warns that antidepressants increase the risk of suicide, especially in adolescents and children. Anyone taking antidepressants should be carefully screened for suicidal tendencies. If you plan to take antidepressants, discuss the risk with your doctor and always read the information on the package. nine0003

Botox in the treatment of chronic migraine

Botox is used to treat and prevent chronic migraine attacks in adults. Chronic migraine is referred to as having a headache for more than 15 days a month, 8 or more of which are accompanied by migraine-like symptoms.

Non-drug treatments

Drug therapy for migraine is often combined with biofeedback, cognitive behavioral therapy, or relaxation techniques. nine0003

Biofeedback is a technique used to gain control over a function that would normally operate automatically (such as blood pressure or pulse rate). The function can be controlled. Relaxation techniques are applied to change function. Biofeedback uses electronic or electromechanical instruments to observe, measure, process, and feed back information about blood pressure, muscle tension, heart rate, brain waves, and other psychological functions. nine0003

This technology can be used at home with a portable device. The ultimate goal of this treatment is to wean the patient off the machine so that they can apply the biofeedback technique at the first sign of a headache.

Through relaxation techniques, one can learn to counteract muscle tension by relaxing the mind and body using yoga, meditation, progressive relaxation, and imagery. Relaxation techniques can be used with or without biofeedback. nine0003

Cognitive Behavioral Therapy

This therapy helps to identify what is causing headaches. People who get migraine experience the same stressors as everyone else, but in migraine patients, stress can trigger migraine attacks. Thus, through specific stress management training, the thoughts, feelings, and behaviors that influence the onset of headaches can be identified and managed so that headaches do not occur. nine0003

Diet therapy

Some migraine sufferers benefit from a course of treatment focused solely on avoiding foods and drinks that cause headaches.