Nortriptyline chemical structure
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Pamelor

Nortriptyline hydrochloride is 1-Propanamine, 3-(10,11-dihydro, 5H-dibenzo cyclohepten- 5-ylidene)-N-methyl-,hydrochloride. It is a second generation tricyclic antidepressant marketed under the tradenames Aventyl® and Pamelor®. It is used in the treatment of depression and childhood nocturnal enuresis (bedwetting). In addition it is sometimes used for chronic pain modification. more...

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Clinical Pharmacology

Nortriptyline inhibits the reuptake of norepinephrine (noradrenalin) and, to a lesser extent, serotonin. Operant conditioning techniques in rats and pigeons suggest that nortriptyline has a combination of stimulant and depressant properties.

Indications

FDA-approved for treatment of depressive disorders. In UK also may be used for treating nocturnal enuresis with courses of treatment lasting no moer than 3 months. Also off-label used for the treatment of panic disorder, prevention of migraine headaches and chronic pain or neuralgia modification (particularly Temporomandibular joint disorder).

Metabolism

Nortriptyline is metabolised in the liver by hepatic enzyme CYP2D6. Approximately 7 to 10 percent of caucasians are poor metabolisers and might experience more adverse effects, thus, a lower dosage is often necessary in these individuals. Blood levels of nortriptyline should be obtained during long term treatment to avoid toxicity and optimise response.

Dosage

25 - 75mg at bedtime. The dosage may be higher or lower depending on your prescribing physician. Doses above 150 mg/day are not recommended.

Side Effects

Dry mouth, drowsiness, orthostatic hypotension, urinary retention, constipation, and rapid or irregular heartbeat. Some sexual side effects may be a problem as well. Less commonly, seizures and ECG/EKG changes have been reported, especially in overdose. However, the incidence of side effects with nortriptyline is somewhat lower than with the first generation tricyclics (e.g. imipramine (Tofranil®), amitriptyline (Elavil®)).

Warnings

Persons with a history of cardiovascular disease, stroke, glaucoma and/or seizures should be given nortriptyline only under close supervision as well as those who are hyperthyroid or receiving thyroid medication. Patients should be cautioned against the use of alcohol during nortriptyline therapy.

Precautions

Pregnancy and lactation. Children under the age of 18.

Contraindications

In the acute recovery phase after myocardial infarction (e.g. heart attack). Do not use MAO Inhibitors (e.g. phenelzine, tranylcypromine, etc) with nortriptyline as hyperpyretic crises, severe convulsions, and fatalities have occurred when similar tricyclic antidepressants were used in such combinations.

Do not use if you have had serious reactions to other tricyclic antidepressants unless under the close supervision of your prescribing physician.

Overdose

Deaths may occur from overdosage with tricyclic antidepressants. Serious cardiac arrhythmias and coma are also possible. Keep this medication away from infants and children in a child-proof container.

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Rebound headaches
From American Family Physician, 12/15/04

What are rebound headaches?

Headaches that happen every day or almost every day may be caused by overuse of pain medicines. Often these headaches begin early in the morning. The location and severity of the headache may change from day to day. People who have rebound headaches also may have nausea, anxiety, irritability, depression, or problems sleeping.

What kinds of medicine can cause rebound headache?

Both prescription and over-the-counter medicines for migraine (such as aspirin and acetaminophen) can cause headache if you take them too often. These medicines should not be taken on more than two days per week. Sedatives, tranquilizers, and ergotamine medicines also can cause rebound headache. Talk with your doctor to find out if you should stop taking these medicines, or take less of them.

Should I stop taking certain medicines?

Talk to your doctor about the medicines you are taking. You can safely stop taking some medicines right away. Other kinds of medicine have to be slowly reduced, little by little. After stopping the medicine that is giving you rebound headaches, your headaches may get worse for a few days. Do not make changes to your drug plan without talking with your doctor.

What effect does caffeine have on headaches?

Caffeine is an ingredient in some headache medicines. It may make your headache feel better for a little while. But if you take medicine with caffeine every day, or if you drink a beverage with caffeine every day, you might get more headaches. If your headache gets worse when you stop having caffeine, the caffeine may be causing some of your headaches.

How should I use medicine for my daily headaches?

There are several common medicines to prevent headaches. Medicines to prevent headache have to be taken every day. Here are some medicines that prevent headaches:

* Tricyclic antidepressants, such as amitriptyline (brand name: Elavil) and nortriptyline (brand name: Pamelor)

* Antiepileptic drugs, such as valproic acid (brand name: Depakote), gabapentin (brand name: Neurontin), and topiramate (brand name: Topamax)

* Beta blockers, such as propranolol (brand name: Inderal)

These medicines can help you get fewer headaches. But they will not stop every headache. It may take six weeks or more for your medicine to start working. Talk to your doctor about which medicines are right for you. It is important to follow your doctor's directions when you take these medicines.

What can I do to help my headaches?

Take medicines only as directed by your doctor. Take only the headache medicines recommended by your doctor, including over-the-counter medicines. Always have your medicines with you in case you begin to get a headache. Keep a headache diary so you and your doctor know what helps and when you are getting headaches.

Following a regular daily pattern will help. Eat meals at regular hours and do not skip breakfast. Fasting is a common cause of headache. Go to bed and get up at the same time every day. Regular aerobic exercise is helpful. You should exercise at least 20 minutes a day, three days a week. Yoga, meditation, relaxation therapy, and simple pleasurable activities may help. Your doctor may ask you to keep a headache calendar to help track your headache progress.

What about natural therapies and alternative medicines?

Natural supplements that may help to prevent your migraines include vitamin [B.sub.2], magnesium, feverfew, coenzyme [Q.sub.10], and butterbur root (Petasites hybridus). Many patients seek alternative therapies for headache relief. Acupuncture or chiropractic treatments may help your headaches. But, there is no proof that these treatments help. Be sure to tell your doctor about any natural medicines or supplements you are taking.

COPYRIGHT 2004 American Academy of Family Physicians
COPYRIGHT 2004 Gale Group

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