Medication Names:

Amitriptyline (Elavil®)
Nortriptyline (Pamelor®)
Imipramine (Tofranil®)
Desipramine (Norpramin®)
Doxepin (Sinequan®)
Vivactil (Protriptyline®)
Maprotiline (Ludiomil®)
Trazodone (Desyrel®)
Amoxapine (Ascendin®)

Citalopram (Celexa®)
Fluoxetine (Prozac®)
Sertraline (Zoloft®)
Paroxetine (Paxil®)
Venlafaxine (Effexor XR®)

Mirtazapine (Remeron®)
Nefazodone (Serzone®)
Buproprion (Wellbutrin SR®)

MAO Inhibitors
Tranylcypromide (Parnate®)
Phenelzine (Nardil®)

Membrane Stabilizers
Gabapentin (Neurontin®)
Valproate (Depakote®)
Clonazepam (Klonopin®)
Lamotrigine (Lamictyl®)
Topiramate (Topiramax®)
Phenytoin (Dilantin®)

On Label Use:


Pain Use:

Tricyclic Analgesics: Neuropathic pain, CRPS 1, CRPS 2, sleep disturbance, fibromyalgia

All: Depression, Anxiety, Post Traumatic Stress Disorder

Tricylics, Nefazodone,Trazodone, Vanlefaxine, Mirtazepine: Sleep disturbance with depression

Therapeutic Benefit:

Improvement of depression and anxiety.

Dose Range and Titration:

Nortriptyline (Pamelor®) 75 mg to 150 mg at bedtime: Increase by 25 mg q 1-2 weeks

Desipramine (Norpramin®) 75 mg to 125 mg at bedtime: Increase by 25 mg q 1-2 weeks

Amitriptyline (Elavil®) 100 mg to 300 mg at bedtime: Increase by 25 mg q 1-2 weeks

Doxepin (Sinequan®) 150 mg to 300 mg at bedtime: Increase by 25 mg q 1-2 weeks

Citalopram (Celexa®) 20mg to 60 mg in AM: Increase by 20 mg q 1-2 weeks

Fluoxetine (Prozac®) 20 mg to 80 mg: Increase by 20 mg q 2-3 weeks

Sertraline (Zoloft®) 50 mg to 200 mg: Increase by 50 mg q 2-3 weeks

Paroxetene (Paxil®) 20 mg to 50 mg: Increase by 10 mg q 2-3 weeks

Venlafaxene (Effexor XR®) 75 mg to 300 mg: Increase by 75 mg XR every 2-3 weeks- Noradrenergic effects start at 150 to 225 mg

Nefazodone (Serzone®) 100 to 600 mg: Increase by 100 mg q 1-2 weeks- Do not use with Fluoxetine.

Mirtazepine (Remeron®) 15 to 60 mg: Increase by 15 mg q 2 weeks

Buproprion (Wellbutrin SR®) 150mg to 300mg: Increase by 150 mg in 1 week bid

Membrane Stabilizers are best left to a psychiatrist for managing depression and usually should be used in concert with a more traditional antidepressant. The same doses that are useful in pain control can be effective with depression and anxiety.

MAO Inhibitors should be left to psychiatrists to use.

Some of these medications can be used in combinations with each other and this may be quite helpful in treating depressive disorders. Unless a practitioner is very experienced with the use of antidepressants and understands the various drug/drug interactions, this should be done by psychiatrists only.


Side Effects:

Amitriptyline, Imipramine, Nortriptyline, Doxepin, Desipramine, Protriptyline, and Amoxapine: Dry mouth, blurred vision, drowsiness, constipation, urinary retention, hangover effects, sleeplessness, loss of libido, cardiac arrythmias.

Maprotiline lowers the seizure threshold and is more likely to precipitate seizures than the other antidepressants. It can also cause similar side effects to the tricyclics.

Trazodone causes a high degree of sedation and can cause priapism.

SSRIs: GI hypermotility, anxiety, loss of libido, delayed orgasm

Buproprion in non-SR formulation increases the risk of seizures (4.0%), while in SR formulation this risk is the same as with other antidepressants (0.4%). Buproprion can cause agitation and sleep disturbance.

MAO inhibitors: hypotention and sedation. In combination with tyramine containing foods or many medications these may cause malignant hypertenstion, stroke and death. That is why their use is best left to psychiatrists familiar with the interactions.

Membrane stabilizers: Sedation, ataxia, nausea, vomiting, confusion, forgetfulness. Lamotrigine is associated with Stevens-Johnson's syndrome. Carbamazepine can cause aplastic anemia. All of them with the exception of Clonazepam and gabapentin may increase liver enzyme levels.

Drug Interactions:

Levels may be increased precipitously by SSRI's with high protein binding or Cytochrome P450 2D6 metabolizing pathways.This is most significant with Fluoxetine and Sertraline and is less so with Piroxicam. Special care should be taken with combinations of these medications with tricyclics as small dose changes in the tricyclic can cause dramatic and toxic seum trcylclic concentrations. Citalopram has negligible drug interactions, as does Remeron, making them both desireable for treatment with other medications.

Amitriptyline and Imipramine should not be used with Methadone due to potential malignant arrythmias.

MAO inhibitors have many drug interactions and their use should be left to experienced psychiatrists

Dependency or Abstinence Syndrome:

There may be rebound insomnia or tachycardia with abrupt cessation. Titrate downward over a few days to a few weeks.

Serotonergic abstinence sydrome may occur with the SSRI's, especially short acting Piroxicam. These should be slowly lowered, when discontinued. The symptoms are of a flu-like syndrome without temperature elevation.

Stopping membrane stabilizers abruptly increasses the risk of seizures. Clonazepam cessation can cause full blown delerium tremens, grand mal seizures and death due to a benzodiazepam withdrawal syndrome.




Bay Area Pain Medical Associates provides the information as a guideline for physicians interested in up to date knowledge about the treatment of pain in their patients. We provide this as a public service without endorsing any specific treatment. Much of the medication used in managing pain is for "off label" use. Physicians using these medication are responsible for researching their efficacy, side effects, therapeutic benefits, interactions, titration and cessation, before deciding whether to use them in their practice. While we have provided information on these subjects, we do not feel this should serve as a substitute for looking up medications in standard texts and resources. When medications are left out of dosing, titration, drug interaction and side effect categories, it is because we do not think they should be used by anyone except for pain specialists.