Migraine can be difficult to diagnose — and even harder to treat — which means many people seek emergency care when they can’t find relief. In the United States, more than 1 million emergency department visits each year are for migraine pain.
During a migraine attack, there’s a drop in serotonin levels. As researchers look outside the box to treat migraine, some have found that antidepressants that balance serotonin levels may be helpful in preventing migraine from happening in the first place.
Keep reading to learn about the role of tricyclic antidepressants (TCAs) in migraine treatment and what you need to know before taking them.
FDA warning: Suicide risk
- This drug has a black box warning. This is the most serious warning from the Food and Drug Administration (FDA). A black box warning alerts consumers about drug effects that may be dangerous.
- Nortriptyline may increase the risk of suicidal thoughts and behavior for people younger than 24 years old. Having depression and a psychiatric history puts you at higher risk for suicide. Your doctor will monitor you for any changes in your depression symptoms and any unusual behavior or thoughts about self-harm.
Nortriptyline is a tricyclic antidepressant. This class of medications works on the central nervous system by increasing the level of serotonin in your brain. Serotonin drops when a migraine attack strikes.
Tricyclic antidepressants like nortriptyline are usually used to treat depression, but there’s some evidence that they can also be beneficial in treating migraine.
There are many theories as to what causes migraine. One of these involves an imbalance in neurotransmitters like serotonin. There are several types of medications that can help balance these neurotransmitters, and nortriptyline is one of them.
While other medications may be used to treat the many symptoms of migraine, antidepressants like nortriptyline may be useful in preventing them.
There are a number of side effects of tricyclic antidepressants. While they may be useful in reducing migraine attacks, there are serious risks to consider, too.
The Food and Drug Administration (FDA) has issued a Black Box warning — the agency’s strongest warning — for nortriptyline. The warning notes that taking this medication can actually increase depression in children, teens, and young adults, resulting in episodes of major depressive disorder (MDD) and even a risk for suicide.
More common side effects of this medication include:
- nightmares or trouble sleeping
- dry mouth
- changes in appetite or weight
- changes in urination
- changes in sex drive
- excessive sweating
More serious side effects have been observed in people taking this medication, too. Seek immediate medical care if you experience:
- jaw, neck, or back muscle spasms
- speech changes
- a shuffling walk
- difficulty breathing or swallowing
- yellowing of the skin or eyes
- irregular heart rate or palpitations
- increased depression
- suicidal thoughts
Your doctor will consider your specific health history and tolerance of these medications when choosing the right therapy for you.
These medications are effective in reducing the frequency of migraine attacks because they help to balance neurotransmitter levels that may play a role in migraine development. Other medications may be used to manage symptoms when migraines occur.
Like many other antidepressant treatments, nortriptyline treatment starts with a small dose that can be increased in stages until you’ve reached a therapeutic level. The drug is available in 10 milligrams (mg), 25 mg, 50 mg, and 75 mg formulations.
Dosing usually begins at 25 mg taken at bedtime. You and your doctor will discuss a plan to increase this dosage as needed until your migraine attacks are significantly reduced.
Doses are increased in increments of 25 mg, with a week between each dose increase. The maximum dose is 150 mg per day for adults.
Nortriptyline is available only with a prescription from a doctor. It comes in pill or liquid form. It’s available as a brand-name medication (Pamelor) or as a generic medication.
If you routinely get migraine attacks, make an appointment with your doctor. If you don’t have one, you can use the Healthline FindCare tool to find one in your area.
There are a number of ways to treat migraine, and no one treatment works for everyone. Below are some of the ways migraine can be treated.
Over-the-counter medications may work for some people. Examples of these medications include acetaminophen and nonsteroidal anti-inflammatory drugs (NSAIDs) like:
A number of prescription medications can be used to treat migraine pain and the numerous other symptoms that can accompany them.
Medications aimed at stopping migraine attacks or treating migraine pain include:
- ketorolac (Toradol)
- dihydroergotamine (DHE-45, Migranal)
- ergotamine (Ergomar)
- ergotamine and caffeine (Cafatine, Cafergot, Cafetrate, Ercaf, Migergot, Wigraine)
- methysergide (Sansert)
- methylergonovine (Methergine)
- almotriptan (Axert)
- eletriptan (Relpax)
- frovatriptan (Frova)
- naratriptan (Amerge)
- rizatriptan (Maxalt, Maxalt-MLT)
- sumatriptan (Imitrex)
- sumatriptan and naproxen (Treximet)
- zolmitriptan (Zomig)
- meperidine (Demerol)
- oxycodone (OxyContin)
For nausea that can sometimes accompany migraine attacks, your doctor may prescribe medications like:
- dimenhydrinate (Gravol)
- metoclopramide (Reglan)
- prochlorperazine (Compazine)
- promethazine (Phenergan)
- trimethobenzamide (Tigan)
Nortriptyline isn’t the only medication used in migraine prevention. A number of treatments are available and include:
- erenumab (Aimovig)
- fremanezumab (Ajovy)
- atenolol (Tenormin)
- metoprolol (Toprol XL)
- nadolol (Corgard)
- propranolol (Inderal)
- timolol (Blocadren)
- diltiazem (Cardizem, Cartia XT, Dilacor, Tiazac)
- nimodipine (Nimotop)
- verapamil (Calan, Covera, Isoptin, Verelan)
- amitriptyline (Elavil, Endep)
- fluoxetine (Prozac, Sarafem)
- imipramine (Tofranil)
- paroxetine (Paxil, Pexeva)
- sertraline (Zoloft)
- venlafaxine (Effexor)
- divalproex-sodium (Depakote, Depakote ER)
- gabapentin (Neurontin)
- levetiracetam (Keppra)
- pregabalin (Lyrica)
- tiagabine (Gabitril)
- topiramate (Topamax)
- valproate (Depakene)
- zonisamide (Zonegran)
- Botulinum toxin type A (Botox injections)
One way to manage migraine is with lifestyle changes. There are many triggers for migraine in the foods we eat, stress, and other factors.
Below are some diet, situational, and complementary changes you can make to your lifestyle to help manage migraine:
- Avoid eating food high in nitrates, like processed meats.
- Keep a journal of foods or activities that trigger migraine attacks.
- Use herbs like lavender, feverfew, peppermint oil, and ginger in home remedies.
- Add magnesium to your diet with supplements and foods like legumes and whole grains.
- Try to manage daily stress.
Migraine is a complex neurological condition that can cause many painful symptoms. There’s no one treatment that works for migraine, and most people use several therapies to manage their migraine pain.
Antidepressants like nortriptyline are one class of medication that can help reduce the frequency of migraine attacks, but they may have serious side effects. Speak with a doctor if you need help managing migraine.