Pain Management: Amitriptyline v Nortriptyline

[Rybee]

Hi All,

I'm seeing my doctor tomorrow morning (in 10 hours) so a quick reply with any help or guidance would be appreciated.

I suffer from chronic migraine and need to go back onto prophylactic medication. Before paying to see a private consultant neurologist again (£400/$600 per 40min consultation) I'm going to cover the basics and have my general practitioner prescribe me the primary prophylactics such as Topamax/Tricyclics/Sodium Valproate/Verapamil/GABA's because a private consultant is only going to prescribe me them to start with, before moving on to the more complicated medications such as Methysergide/Isometheptene/Flunarizine/Pizotifen etc... which is when I would actually need their expert help.

From past use of Amitriptyline, Nortriptyline and Dosulepin, I know that I don't tolerate Tricyclics very well, but I need to give them another go since my migraines are now becoming intolerable. I guess in terms of migraine prophylaxis, or neuropathic pain in general, Amitriptyline is probably the first stop on the Tricyclic train, however, I just read that Nortriptyline is actually a 2nd generation active metabolite of Amitriptyline and that it often results in fewer side effects?

However, I don't know whether Nortriptyline's decreased side effects compromises its potency or efficacy when compared to Amitriptyline? I guess I should perhaps start on Amitriptyline and then move over to Nortriptyline if I don't tolerate it too well... or not?

Rybee x

 

[Nicholai]

Full therapeutic benefit for pain relief with amitriptyline is achieved with 20mgs...this is usually a tolerable dose. There isn't any point in taking more...

 

[Rybee]

Well I went for Amitriptyline over Nortriptyline on the basis that if I didn't tolerate Amitriptyline very well then I could always 'drop down' to Nortriptyline.

Starting off this week on 25mg this week and 50mg next week. Considering that I've never tolerated Tricyclics very well, 50mg after just 7 days use is a big jump for me, but I'm in so much pain I'll do anything. The acclimatisation so far has been worse than some withdrawals, though this was anticipated. I'm just hoping that I'll stabilise at 50mg and the pain will start to subside. I've also rapidly tapered off of all opiates and changed from daily use to PRN, so I think I'm feeling the effects of that too.

I've also blacked out twice in the last week and my right side frequently goes numb throughout the day, had a CT scan on my brain 2 days ago and that was clear so has put my mind at ease. Not sure what the blacking out is, but as long as it's not a tumour, I really couldn't care less right now. My mum died of several brain tumours so that was at the forefront of my worries and seemed to explain the blackouts & numbness - which she experienced prior to her diagnosis.

Anybody got any tips on how to acclimatise to TCAs SSRIs SNRIs? - I used a lot of Diazepam when withdrawing from Venlafaxine which helped massively. I know there are a ton of threads on BL about withdrawals, but I've never actually read about smoothing out the acclimatisation period?

Any help is tips & tricks are appreciated

 

[Rybee]

Hey guys - would appreciate any help with the post below with regards to my pain management.

Well, as per my post above and as expected, I couldn't tolerate the Amitriptyline after 5 weeks of use so fully withdrew from it a fortnight ago - opting to 'drop down' to Nortriptyline instead and started taking 25mg as of Monday (08/12/14). So, 5 days in, and to my astonishment, I've not suffered from any notable side effects whatsoever, and plan to titrate up to 50mg starting Monday (15/12/14).

I'm due to withdraw from Oxycodone and switch over to Methadone shortly - though I do have some reservations about it and would like to avoid starting it, if possible, though I have no doubts that it will be a much more effective painkiller for neuropathic pain than Oxycodone. However, if the Nortriptyline can nip the pain in the bud and it's synergetic effects, mixed with Oxycodone, Paracetamol/Acetaminophen, and Naproxen/Aleve/Naprosyn, significantly improve my levels of pain, then I'm hoping I can resist the switch to Methadone, since I've got some concerns and reservations about changing to it - despite some of it's attractive qualities.

So my question really is, what dose of Nortriptyline do people take for pain management, and how many weeks can I expect it's effects to kick in at?

My pain doctor has instructed my GP to prescribe:
Week 1 - 25mg Nortriptyline
Week 2 - 50mg Nortriptyline
Week 3 - 75mg Nortriptyline
Week 4 - 100mg Nortriptyline, subject to two conditions:
-------- - A) That, a correlation indicates that my levels of pain have reduced since starting the Nortriptyline to demonstrate it's efficacy.
-------- - B) That I am suffering from no moderate-to-severe or red flag side effects. Considering that I've never tolerated Tricyclics so well before, this is very promising so far.

I've got to wait a fair while to wait before I can switch to Methadone, since the area I live in runs a 'single provider scheme' in which only one clinic in the area has the authority to initially prescribe, dispense and administer Methadone. Once a dose has been titrated it can then be obtained by my doctor and I'll check into the clinic for monthly reviews. The first purpose of which is so that the clinic can supervise everybody starting on Methadone and titrating up their doses in the early stages so as to be on hand to offer great patient care. Secondly, a single provider system results in an incredibly tightly controlled dispensation system for Methadone prescriptions so as to ensure that neither the service nor system are being abused, and that the drug is used with the care and supervision that Methadone requires. It's a very busy clinic as it is run by my local Drugs & Alcohol service who also take on referrals from pain management patients, so there's a bit of a wait.

My current regime drawn up by my pain management consultant, until I switch to Methadone involves a lot of opiate rotation in order to try and get a vast cross section of my opiate receptors to be kept on their toes on a daily basis and I think it's working very well so far. I'm in certainly less pain than when I was previously sticking to just a single opiate (Oxycodone) and my pain diary has since shown a marked decrease in my overall pain - when compared to 2 weeks ago. I accepted my schedule may seem a little bit unorthodox (arguably unnecessary?) but that's why I like him. He's proactive, instead of reactive, creative, inventive, and imaginative - whilst and always going the extra mile to help me fight the pain by using such abstract ideas. This is in significant contrast to all of my previous pain management consultants who's only generic answer is to 'just carry on increasing your Oxycodone dose until you find it's working' - a sure way to end up in a right pickle. So here it is:


Table Key:
First Number: Day of the Week
Letter W:1x25mg Nortriptyline
Letter X: 1x50mg Nortriptyline
Letter Y: 1x75mg Nortriptyline
Letter Z: 1x100mg Nortriptyline
Letter A: 2x40mg MS Contin
Letter B: 4x10mg Oxycodone
Letter C: 2x100mg Tapentadol
Letter D: 1x25µg 72hr Transdermal Fentanyl Patch


Week One:
1WA: 1x25mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
2WB: 1x25mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
3WC: 1x25mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
4WA: 1x25mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
5WB: 1x25mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
6WC: 1x25mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
7WD: 1x25mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)


Week Two:
1XD: 1x50mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
2XD: 1x50mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
3XA: 1x50mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
4XB: 1x50mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
5XC: 1x50mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
6XA: 1x50mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
7XB: 1x50mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)


Week Three:
1YC: 1x75mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
2YD: 1x75mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
3YD: 1x75mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
4YD: 1x75mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
5YA: 1x75mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
6YB: 1x75mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
7YC: 1x75mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)


Week Four:
1ZA: 1x100mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
2ZB: 1x100mg Nortriptyline & 4x10mg Oxycodone (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
3ZC: 1x100mg Nortriptyline & 2x100mg Tapentadol (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
4ZD: 1x100mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
5ZD: 1x100mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
6ZD: 1x100mg Nortriptyline & 1x25µg 72hr Transdermal Fentanyl Patch (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)
7ZD: 1x100mg Nortriptyline & 2x40mg MS Contin (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)


Week Five:
Hopefully would have started 20-30mg Methadone in conjunction with 100mg Nortriptyline and 1x10mg Oxycodone P.R.N. for breakthrough pain (inclusive of 1g Acetaminophen + 500mg Naproxen/Aleve PRN)

The only think that's really troubling me at the moment is opiate induced constipation, though this is significantly less of a problem on the Topiramate days - so I try my hardest to shit on that day.

 

[kayaker318]

^Rybee - Amazing that you were able to create that chart is my first thought. Did you get a migraine afterwards? I, too, suffer from chronic migraines. I have never tolerated the tricyclics well at all so they didn't help in my case. I honestly feel that they're dirty drugs w/too many side effects but great if they help you. With all of that other medication why even bother with the Nortriptyline? I would think that everything else would take care of the pain.

I take Oxycodone IR 40/mg daily, Lexapro (SSRI) as well as, Aleve and Amerge (naratriptan) on really bad days. Have you ever considered a triptan in your migraine meds cocktail?

 

[paranoid android]

Hmm i have taken Amitriptyline and Trimipramine both for neuropathic pain as well as bipolar depression. I have no problem tolerating high doses of either and i find them to be very tolerable much unlike newer anti-depressants like say Effexor which made Dilaudid wd look fun by comparison. Amitriptyline does a equal reuptake of both Serotonin and Norepinephrine where as Nortriptyline mostly acts as a NRI. So it tends to be less sedating as the NRI effects kinda offset the anti-cholinergic effects. However Amitriptyline can be more effective for some people. Trimipramine would be worth a try in my opinion as well though some people do find it to be even more sedating then Amitriptyline i don't find it bad.

 

[Rybee]

^Rybee - Amazing that you were able to create that chart is my first thought. Did you get a migraine afterwards? I, too, suffer from chronic migraines. I have never tolerated the tricyclics well at all so they didn't help in my case. I honestly feel that they're dirty drugs w/too many side effects but great if they help you. With all of that other medication why even bother with the Nortriptyline? I would think that everything else would take care of the pain.

I take Oxycodone IR 40/mg daily, Lexapro (SSRI) as well as, Aleve and Amerge (naratriptan) on really bad days. Have you ever considered a triptan in your migraine meds cocktail?

Haha, thank you. Yeah, I was a little bored so went a bit over the top with that chart.

So I've been on Nortriptyline for 3 weeks now (as below) and haven't suffered a single side effect. The only thing I do feel is a bit groggy the first morning after upping my dose.

Week 1: 25mg
Week 2: 50mg
Week 3: 75mg

The Nortriptyline seems far superior to Amitriptyline and Dosulepin in terms on side effects which is such a relief. I've not had a migraine since I've started taking it.

Yup I have tried Triptan's, my GP was kind enough to prescribe me a 'Pick 'n Mix' of them, to see which one, if any, worked best. He prescribed me 2x pills of Sumatriptan, Zolmitriptan, Rizatriptan, Naratriptan and Frovatriptan. Rizatriptan worked noticeably better than Sumatriptan, slightly better than Naratriptan and Frovatriptan and marginally (if any) better than Zolmitriptan - but comes available in a quickly absorbed orodispersible tablet form that dissolves on the tongue so I went with that in the end.

I'd only really tried Sumatriptan before as it's generally touted as the best one to go with, and never had any success whatsoever with tablets, nasal sprays or even the injections (an epi pen kinda thing). One doctor told me that they were pretty much all the same and if I didn't respond well to Sumatriptan injections then the rest wouldn't be worth trying... she couldn't have been more wrong.

So yeah, nearly a month of no migraines now. Nortriptyline is working as a prophylaxis, Rizatriptan works well as an abortive and then if I still need a little more, I can always take a big dose of Oxycodone and Naproxen.

I've also been accepted for treatment with botox injections so I should have that some time in January. Looks like it has quite a high success rate.

So all things dandy so far!

Hmm i have taken Amitriptyline and Trimipramine both for neuropathic pain as well as bipolar depression. I have no problem tolerating high doses of either and i find them to be very tolerable much unlike newer anti-depressants like say Effexor which made Dilaudid wd look fun by comparison. Amitriptyline does a equal reuptake of both Serotonin and Norepinephrine where as Nortriptyline mostly acts as a NRI. So it tends to be less sedating as the NRI effects kinda offset the anti-cholinergic effects. However Amitriptyline can be more effective for some people. Trimipramine would be worth a try in my opinion as well though some people do find it to be even more sedating then Amitriptyline i don't find it bad.

Yeah, the Nortriptyline is definitely less sedating than the Amitriptyline, for sure. I've never heard of Trimipramine so gonna give that a Google.

 

[Sphinx8]

Page 27 of "Heal Your Headache" by Buchholz, M.D. of Johns Hopkins might explain the black out.