Nortriptyline (Pamelor): dosage, uses, side effects

It can be surprising to learn that certain medications are “antidepressants” when healthcare providers prescribe them for conditions other than depression. One such example is nortriptyline, an antidepressant that providers sometimes use to treat pain or prevent migraines, among other uses.

Read on to learn about nortriptyline’s uses, side effects, dosage, and more.

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Nortriptyline is an antidepressant medication. It belongs to an older class of prescription drugs called tricyclic antidepressants (TCAs). How TCAs work isn’t known for sure, but it’s thought that TCAs like nortriptyline work by enhancing the availability of neurotransmitters that regulate mood, such as norepinephrine and serotonin (Mallinckrodt, 2016).

After receiving its approval by the Food and Drug Administration (FDA) in 1964, nortriptyline, also called nortriptyline hydrochloride or HCl, was prescribed under the brand-name medications Aventyl and Pamelor. However, it’s now only available as a generic drug, which comes in capsule and oral solution forms (FDA, n.d.; Mallinckrodt, 2016).

The FDA approves nortriptyline to treat depression (also known as major depressive disorder or unipolar depression) in adults and adolescents. It is not approved for children (Mallinckrodt, 2016).

In the past, healthcare providers would commonly prescribe nortriptyline for depression. But there was a change in the late 1980s when a “new-and-improved” class of antidepressants—selective serotonin reuptake inhibitors (SSRIs)—became available. SSRIs tend to cause milder side effects and have fewer safety risks than TCAs, so even though nortriptyline is FDA-approved for depression, it is no longer well-known for this use (Chockalingam, 2019; Merwar, 2021). 

Now, healthcare providers sometimes prescribe it “off-label” to treat conditions other than depression. With off-label use, a healthcare provider can prescribe a medication for reasons other than its specific FDA-approved uses if they decide that it’s the proper treatment.

Off-label uses for nortriptyline include (Merwar, 2021):

• Chronic pain

• Diabetic neuropathy: a complication of diabetes that causes nerve pain and other symptoms like numbness or tingling

• Postherpetic neuralgia: nerve damage caused by a shingles infection that leads to pain and other nerve-related discomforts

• Smoking cessation, as in a medication that can help people quit smoking

• Migraine prevention (Burch, 2019)

Common side effects of nortriptyline include (Mallinckrodt, 2016):

• Drowsiness

• Dry mouth

• Dizziness

• Constipation

• Blurred vision

• Sweating

• Heart palpitations or irregular heartbeat

• Fast heart rate

• Increased appetite

• Weight gain

Less frequently, some people develop other side effects, such as: 

• High blood pressure

• Sudden drop in blood pressure upon standing or sitting up, called orthostatic hypotension. This side effect can cause dizziness or fainting.

• Heart rhythm problems, heart attack, or stroke

• Trouble with balance or coordination

• Confusion

• Slurred speech

• Skin rash 

• Urinary retention (trouble with completely emptying your bladder when you urinate)

• Heatstroke

For safety, it’s best to avoid driving until you become familiar with how nortriptyline affects you. If you have questions about these side effects, talk to a healthcare provider or pharmacist. 

Nortriptyline is an oral medication. It is available as a capsule (10-mg, 25-mg, 50-mg, and 75-mg) and a liquid solution (10 mg per 5 mL) (Mallinckrodt, 2016; Merwar, 2021).

Its prescribed dosing starts at 25 to 50 mg per day. Your healthcare provider may gradually increase your dose, depending on how well you tolerate the medication. Sometimes, healthcare providers prescribe it in multiple daily doses, up to three to four times per day.

Remember to always consult your healthcare provider before stopping this medication or changing your dose. Suddenly stopping nortriptyline can cause unpleasant withdrawal symptoms. So, if you and your healthcare provider decide that you’ll stop taking it, they’ll guide you on slowly decreasing your dose before you completely stop it.

The Food and Drug Administration (FDA) requires antidepressants, like nortriptyline, to carry a boxed warning for possible worsening of depression and suicidal thoughts or behaviors, a rare but serious risk. 

Medical providers mainly see this increased risk in children, teens, and young adults up to age 25, especially during the early stages of treatment or after dose increases. If you notice changes in how you think and act since starting nortriptyline or have thoughts of harming yourself, help is available. Tell your healthcare provider right away or seek medical assistance (Mallinckrodt, 2016).

Other precautions

Before prescribing nortriptyline, your healthcare provider will discuss your medical history with you. Since certain conditions or factors may increase your risk of severe side effects from this medication, your healthcare provider will want to know if (Mallinckrodt, 2016):

• You had an allergic reaction to nortriptyline or any other TCAs, such as amitriptyline, imipramine, clomipramine, or doxepin

• You are recovering from a recent heart attack or stroke

• You are pregnant or breastfeeding

• You drink alcohol regularly or heavily

• You have certain medical or mental health conditions like Brugada syndrome, a genetic condition that affects the heart; bipolar disorder or other mental illness; heart disease; glaucoma; bladder problems; overactive thyroid; liver or kidney disease

Several medications, including nortriptyline, can increase levels of serotonin, a brain chemical that affects your mood. Taking certain medicines along with nortriptyline could cause serotonin levels to become too high, and in rare cases, cause something called serotonin syndrome. Serotonin syndrome is rare and can be mild or severe. The following medications can raise the risk of serotonin syndrome if taken with nortriptyline (Mallinckrodt, 2017):

• Monoamine oxidase inhibitor ( such as phenelzine, tranylcypromine, linezolid, rasagiline

• Other tricyclic antidepressants ( like amitriptyline, clomipramine, doxepin, and imipramine

• Selective serotonin reuptake inhibitors ( like citalopram, escitalopram (brand name Lexapro), fluoxetine (brand name Prozac), and sertraline (brand name Zoloft)

• Serotonin-norepinephrine reuptake inhibitors ( such as duloxetine (brand name Cymbalta) and venlafaxine (brand name Effexor XR)

• Buspirone(brand name Buspar), an anti-anxiety drug

• Cimetidine, an antacid 

• Triptans, a migraine medication

• Tramadol, a pain medication

• St. John's Wort an herbal supplement

Nortriptyline can interact with several other medications; the list above contains just a few examples. Your healthcare provider or pharmacist can provide more information about your drug interactions, so before taking nortriptyline, be sure to tell your pharmacist about any medications or supplements you currently take so they can check for possible interactions with your other medications.

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Every article on Health Guide goes through rigorous fact-checking by our team of medical reviewers. Our reviewers are trained medical professionals who ensure each article contains the most up-to-date information, and that medical details have been correctly interpreted by the writer.

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Current version

October 27, 2021

Written by

Patricia Weiser, PharmD

Fact checked by

Felix Gussone, MD

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About the medical reviewer

Felix Gussone, MD, Ro

Felix Gussone is a physician, health journalist and a Manager, Medical Content & Education at Ro.