Nortriptyline vs. amitriptyline: Uses, dosages, cost, and side effects

In this article:

• Main differences
• Conditions treated
• Efficacy
• Insurance coverage and cost comparison
• Side effects
• Drug interactions
• Warnings
• FAQs

In this article

• Main differences
• Conditions treated
• Efficacy
• Insurance coverage and cost comparison
• Side effects
• Drug interactions
• Warnings
• FAQs

Nortriptyline and amitriptyline are generic medications used to treat depression and other conditions. They are part of a class of drugs called tricyclic antidepressants, or TCAs. They work by increasing levels of neurotransmitters (chemical messengers) called serotonin and norepinephrine in the brain. These neurotransmitters are associated with mood, memory, energy, appetite, attention, focus, and many other functions. Both medicines are known as TCAs and are similar; the body converts amitriptyline into nortriptyline. However, they do have some differences. Continue reading to learn more about nortriptyline and amitriptyline.

RELATED: What is nortriptyline | What is amitriptyline 

What are the main differences between nortriptyline and amitriptyline?

Both nortriptyline and amitriptyline are generic tricyclic antidepressants that are taken by mouth. Nortriptyline is available as a capsule and liquid, and amitriptyline is available in tablet form. 

Main differences between nortriptyline and amitriptyline
Drug class	Tricyclic antidepressant	Tricyclic antidepressant
Brand/generic status	Generic	Generic
What is the brand name?	Pamelor	Elavil (the brand-name drug is no longer available)
What form(s) does the drug come in?	Oral capsule (brand and generic): 10 mg, 25 mg, 50 mg, and 75 mg Oral solution (generic only): 10 mg per 5 mL	Oral tablet: 10 mg, 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg
What is the standard dosage?	Varies; an example dose is 25 mg by mouth 3 or 4 times daily Older adults will be prescribed lower dos.es	Varies; an example dose is 75 mg by mouth in divided doses such as 25 mg 3 times daily Older adults will be prescribed lower doses
How long is the typical treatment?	Varies	Varies
Who typically uses the medication?	Adults	Adults; sometimes prescribed in pediatric patients 12 years and older

Conditions treated by nortriptyline and amitriptyline

Nortriptyline and amitriptyline are approved by the FDA to treat depression. However, healthcare providers sometimes prescribe tricyclic antidepressants off-label. Both nortriptyline and amitriptyline have various off-label uses; some examples can be found in the table below.

Condition	Nortriptyline	Amitriptyline
Depression	Yes	Yes
Chronic pain	Off-label	Off-label
Diabetic neuropathic pain	Off-label	Off-label
Persistent myofascial pain	Off-label	No
Trigeminal neuralgia	Off-label	No
Postherpetic neuralgia	Off-label	Off-label
Smoking cessation	Off-label	No
Migraine prevention	Off-label	Off-label
Neurogenic cough	Off-label	No
Irritable bowel syndrome with diarrhea (IBS-D)	Off-label	Off-label
Anxiety disorders	Off-label	Off-label
Fibromyalgia	No	Off-label
Insomnia	No	Off-label

Is nortriptyline or amitriptyline more effective?

Because nortriptyline and amitriptyline are very similar in efficacy. Results of clinical studies confirm this, such as a study that found both drugs were equally effective in treating depression. 

It’s important to note that medication is generally used in combination with therapy for depression. Also, clinical guidelines do not recommend TCAs as a first choice for treatment in older adults because of their side effects and risks in this age group. TCAs are generally used in individuals who have not responded well to other antidepressants, such as an SSRI or SNRI, which have fewer side effects and are safer in older adults.

Only your healthcare provider can determine the best treatment for you. Consult your healthcare provider for more information about the best treatment for your condition. 

Coverage and cost comparison of nortriptyline vs. amitriptyline

Most commercial insurance and Medicare prescription plans cover generic nortriptyline and amitriptyline. Out-of-pocket costs will vary by plan. 

For those without insurance, a one-month prescription of nortriptyline costs about $30. However, using a SingleCare card or coupon, you could pay as low as $4.

A one-month supply of amitriptyline costs about $26 for uninsured patients, but if you use a SingleCare card or coupon, you can pay as little as $4.

Nortriptyline vs. amitriptyline costs
	Nortriptyline	Amitriptyline
Typically covered by insurance?	Yes	Yes
Typically covered by Medicare Part D?	Yes	Yes
Quantity	30, 25 mg capsules	30, 25 mg tablets
Typical Medicare copay	$0-20	$0-10
SingleCare cost	$4	$4

Common side effects of nortriptyline vs. amitriptyline

The most common side effects of both drugs include:

• Nausea and vomiting
• Drowsiness
• Weakness
• Tiredness 
• Nightmares 
• Dry mouth
• Constipation 
• Difficulty urinating
• Sexual problems
• Excessive sweating 
• Appetite changes
• Weight changes
• Excitement
• Anxiety
• Headache
• Blurry vision 
• Confusion
• Unsteadiness
• Pain, burning, or tingling in the hands or feet

In rare cases, serious adverse effects may occur. People with symptoms of an allergic reaction, such as hives, difficulty breathing, or swelling of the face, lips, tongue, or throat, should seek emergency medical attention. 

Both drugs, as with all antidepressants, have a black box warning, which is the most serious warning required by the FDA. The warning states that antidepressants may increase the risk of suicidal thoughts and behaviors, especially in children and young adults. People of any age who take antidepressants should be closely monitored for changes in mood and behavior or thoughts of suicide. 

This is not a full list of side effects, and others may occur. Consult your healthcare provider for more information and a full list of side effects.

Drug interactions of nortriptyline vs. amitriptyline

Before you take nortriptyline or amitriptyline, tell your healthcare professional about all the medications you take. This includes prescription drugs, OTC medicines, and natural products like vitamins or supplements.

Monoamine oxidase inhibitors (MAOIs or MAO inhibitors) in combination with nortriptyline or amitriptyline can be very dangerous and can even cause death. The use of MAO inhibitors should be separated from TCAs by at least 14 days. 

Using nortriptyline and amitriptyline in combination with other drugs that increase serotonin, including selective serotonin reuptake inhibitors (SSRIs), serotonin and norepinephrine reuptake inhibitors (SNRIs), or other tricyclic medications, can increase the risk of serotonin syndrome, a life-threatening condition caused by excess serotonin in the body. 

Many other drugs may interact with nortriptyline and amitriptyline. Consult your healthcare provider for more information about drug interactions and how they may affect you.

Drug	Drug Class	Interacts with nortriptyline?	Interacts with amitriptyline?
Azilect (rasagiline) Eldepryl (selegiline) Nardil (phenelzine) Parnate (tranylcypromine)	MAOIs	Yes	Yes
Amphetamines Lithium Opioid pain medications St. John’s Wort} Triptans (migraine medications)	Drugs that increase serotonin	Yes	Yes
Celexa (citalopram) Lexapro (escitalopram) Prozac (fluoxetine)	SSRIs	Yes	Yes
Cymbalta (duloxetine) Effexor (venlafaxine) Pristiq (desvenlafaxine)	SNRIs (serotonin and norepinephrine reuptake inhibitors)	Yes	Yes
Antihistamines Anxiety medications Muscle relaxants Sleeping pills	Drugs that cause sedation	Yes	Yes
Certain medications for allergies, Parkinson’s disease, urinary problems	Anticholinergic medications	Yes	Yes

Warnings of nortriptyline and amitriptyline

Before you take nortriptyline or amitriptyline, tell your healthcare provider about all of your medical conditions and medical history, including if you are pregnant, planning to become pregnant, or breastfeeding. 

In addition to the black box warning mentioned above, other warnings of both drugs include:

• Older adults are generally more sensitive to the side effects and toxicity of TCAs, such as constipation, blurry vision, confusion, sedation, and delirium. They are also at higher risk for falls. Older adults taking a TCA will be started on lower doses and closely monitored.

• Serotonin syndrome is a potentially life-threatening condition that can occur due to an excessive amount of serotonin. It can be more likely to occur with certain drug interactions but can also happen with a change in the dose of medication. Be alert to symptoms of serotonin syndrome and get emergency medical attention if you experience:
  • Agitation or restlessness
  • Anxiety
  • Changes in mood
  • Confusion
  • Disorientation 
  • Incoordination
  • Sweating
  • Shivering
  • Fever or overheating
  • Fast heart rate
  • High blood pressure
  • Nausea, vomiting, or diarrhea
  • Shaking
  • Stiff muscles

• More serious symptoms can include high fever, seizures, irregular heartbeat, and loss of consciousness.

• Glaucoma: TCAs may trigger a type of glaucoma that requires emergency medical attention. Get emergency medical help if you have vision changes or eye pain.
• Alcohol: Avoid alcohol while taking amitriptyline or nortriptyline.

Frequently asked questions about nortriptyline vs. amitriptyline

What is nortriptyline?

Nortriptyline is a type of antidepressant medication known as a tricyclic antidepressant. It can be used to treat depression, and it also has several off-label uses, such as migraine prevention, chronic pain, and trigeminal neuralgia. It is available as an oral capsule or solution and is taken by mouth. 

What is amitriptyline?

Amitriptyline is also a tricyclic antidepressant. Amitriptyline can be used to treat depression, and it also has several off-label uses, such as migraine prevention, chronic pain, and fibromyalgia. It is available as an oral tablet that is taken by mouth. 

Are nortriptyline and amitriptyline the same?

Both drugs are members of the tricyclic antidepressant drug class. The body converts amitriptyline into nortriptyline, so the two drugs are very similar but not the same. 

Is nortriptyline or amitriptyline better?

Both drugs are similarly effective in treating depression and are generally used along with therapy. In older adults, TCAs are not the first choice for depression treatment due to side effects and risks. Consult your healthcare provider for more information and medical advice.

Can I use nortriptyline or amitriptyline while pregnant?

Consult your healthcare provider for medical advice if you are pregnant or planning to become pregnant. 

Can I use nortriptyline or amitriptyline with alcohol?

Avoid alcohol while taking nortriptyline or amitriptyline. Alcohol can have additive effects with a TCA, causing breathing problems (in the worst-case scenario, it could cause you to stop breathing), extreme sedation, motor impairment, and severely low blood pressure.