Always check the BNF for latest prescribing advice.
Nortriptyline is a tricyclic antidepressant (TCA). It is a metabolite of amitriptyline, with fewer sedative and anticholinergic effects, making it somewhat better tolerated in some patients.
Used both as an antidepressant and at lower doses for chronic pain syndromes such as neuropathic pain and migraine prophylaxis.

⚙️ Mode of Action

Tricyclic antidepressant (TCA) that inhibits reuptake of noradrenaline and serotonin at the presynaptic nerve terminal.
Enhances synaptic neurotransmitter concentrations, improving mood in depression.
Has antihistaminic and anticholinergic receptor-blocking activity → contributes to sedation and side effects.
Analgesic effect in neuropathic pain thought to relate to noradrenaline reuptake inhibition in descending spinal pain pathways.

💊 Indications & Example Doses

Depressive illness:
- Start with a low dose, then increase if necessary to 75–100 mg daily (either in divided doses or as a single dose at night).
- Maximum 150 mg/day.
- Elderly: start lower (e.g. 30–50 mg daily in divided doses) and titrate cautiously.
Neuropathic pain:
- Start with 10 mg once daily at night.
- Titrate gradually according to response and tolerability.
- Usual effective dose 25–75 mg at night.
- Higher doses should only be used under specialist supervision.
Other off-label uses: migraine prophylaxis, nocturnal enuresis (rarely, in children under specialist care).

🔄 Interactions

See BNF for full list.
Avoid with MAOIs (risk of serotonin syndrome or hypertensive crisis).
Caution with SSRIs, SNRIs, tramadol → additive serotonergic effects.
May enhance arrhythmogenic risk with other QT-prolonging drugs.
Additive sedation with alcohol, benzodiazepines, or opioids.

⚠️ Cautions

Use with caution in elderly (confusion, falls, cardiac effects).
Epilepsy – lowers seizure threshold.
Cardiac disease (conduction abnormalities, arrhythmias, recent MI).
Hepatic impairment (metabolised in liver).

🚫 Contraindications

Mania.
Recent myocardial infarction, severe arrhythmias, or heart block.
Untreated narrow-angle glaucoma.
Severe hepatic impairment.

💥 Side Effects

Anticholinergic: Dry mouth, blurred vision, constipation, urinary retention.
CNS: Drowsiness, dizziness, confusion (especially elderly).
CV: Postural hypotension, palpitations, QT prolongation, arrhythmias.
Other: Weight gain, sweating, sexual dysfunction.
Toxic in overdose – cardiac arrhythmias, seizures, coma.

📖 References

BNF – Nortriptyline
Rang & Dale’s Pharmacology – Tricyclic antidepressants.
NICE guideline [CG173]: Neuropathic pain in adults.

📝 Revisions

September 2025 – Expanded with detailed MOA, chronic pain use, cautions, and side effect profile.

The content on this website is provided for educational and informational purposes only to support exam preparation (e.g., MLA, MRCP, USMLE) and learning. This is NOT medical advice, diagnosis, treatment, or professional guidance. It does not replace consultation with a qualified healthcare professional, official guidelines (e.g., NICE, GMC, BNF), or supervised clinical practice. Always verify information with current, authoritative sources. Makindo and its contributors accept no liability for any reliance on this content, including errors, omissions, or any resulting harm, loss, or consequences. By using this site, you agree to these terms.

Nortriptyline 💊

📘 About