Tricyclic Analgesics


Medication Names:

Nortriptyline (Pamalor), Desipramine (Norpramin), Amitriptyline (Elavil), Doxepin (Sinequan)

On Label Use:

Depression (usually at higher doses)

Pain Use:

Neuropathic pain, CRPS 1, CRPS 2, sleep disturbance, fibromyalgia

Therapeutic Benefit:

Decreased burning pain, electrical pain, stabbing pain caused by nerve injury. Improved sleep. Decreased tender point tenderness

Dose Range and Titration:

Nortriptyline 10 mg to 75 mg at bedtime

Desipramine 10 mg to 75 mg at bedtime

Amitriptyline 10 mg to 150 mg at bedtime

Doxepin 10 mg to 150 mg at bedtime

Titrate up q week by one dose increment to maximum dose, good pain relief, or intolerable side effects.

Side Effects:

Dry mouth, blurred vision, drowsiness, constipation, urinary retention, hangover effects, sleeplessness, cardiac arrythmias

Drug Interactions:

Levels may be increased precipitously by SSRI's with high protein binding or Cytochrome P450 2D6 metabolizing pathways.

Dependency or Abstinence Syndrome:

None- there may be rebound insomnia or tachycardia with abrupt cessation. Titrate downward over a few days to a few weeks for daily doses above 30-50 mg daily.





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.