Nortriptyline (Pamelor) is a tricyclic antidepressant that is commonly used as a second-line treatment for major depression. It is also sometimes prescribed for conditions such as chronic fatigue syndrome, bedwetting in children, migraine headaches, and neuropathic pain. The drug may also be effective for some individuals in managing symptoms of attention-deficit hyperactivity disorder (ADHD).
This drug functions primarily as an SNRI, inhibiting the reuptake of both serotonin and norepinephrine. By inhibiting the reuptake of these neurotransmitters, extracellular levels of these neurotransmitters increase, and a person’s mood (or other condition) improves. Nortriptyline has the greatest affinity for the norepinephrine transporter (NET) – meaning it affects norepinephrine more than serotonin.
It also elicits effects on histamine and serotonin, but less than 3-4 times that of norepinephrine. While many people get benefit from taking Nortriptyline, some people find that the side effects are too difficult to handle or that the drug isn’t providing them with enough benefit. In these cases, a person may want to discontinue or withdraw from their medication. Unfortunately, there are often uncomfortable withdrawal symptoms that ensue upon dose-reduction and/or full discontinuation.
Factors that influence Nortriptyline withdrawal
There are several factors that will influence withdrawal from Nortriptyline including: time span over which you took the drug, your dosage, how quickly you tapered, and other individual lifestyle factors (i.e. stress level, sleep duration, social support, etc.). It is these factors that are responsible for different symptoms and withdrawal durations among those that quit.
1. Time Span
How long were you taking Nortriptyline? Those that were taking it for years are likely going to experience more noticeable withdrawals than those who were taking it for a few weeks or months. The longer the term over which you’ve been taking it, the more your physiology will have adapted to the effect of the drug.
It will now expect to receive the drug for increased production of neurotransmitters like norepinephrine and serotonin. Furthermore, long-term users tend to increase their dose over time due to loss of efficacy (as a result of tolerance), making it tougher to discontinue. Short-term and moderate term users will still likely experience symptoms, but they should be less pronounced than those using the drug for an extended period.
2. Dosage (25 mg to 150 mg)
The maximum recommended daily dose for Nortriptyline is 150 mg. Most people are taking smaller doses at multiple times per day (e.g. 50 mg twice per day). Teens aged 13 to 18 taking the drug are not recommended to exceed 50 mg per day. The dosage that you’ve been taking will likely dictate the degree to which your neurotransmitters and neural activity is altered as a result of the drug.
Those that take a high dose, especially for an extended period of time are likely going to face more severe withdrawals than those taking a lower dose. This is why it is recommended to always take the minimal effective dose. Many people don’t understand that there’s no biological free lunch from these drugs; the greater the effect (usually dictated by dose) the greater the consequences.
3. Cold turkey vs. Tapering
If you quit Nortriptyline “cold turkey” or abruptly without conducting a taper, you’re going to experience more severe withdrawals than tapering. Discontinuing cold turkey from any medication, especially a high dose, usually results in the most severe withdrawals. If you’ve been taking a high dose for an extended period of time, it is never recommended to quit cold turkey.
Quitting cold turkey may shock your nervous system, leading to a longer, more protracted withdrawal as your physiology scrambles to make changes. Although tapering off of Nortriptyline may require more time and patience, it allows your physiology to gradually adapt to reductions in dosing. Symptoms tend to be noticeably less severe with a gradual taper than cold turkey.
If you want to taper, it is recommended to reduce your dosage at a rate of 10% per month. If you are able to tolerate 10% easily, then you could increase the speed to 15% or 20% – but proceed with caution. If 10% seems like too quick of a taper, you can adjust and go with 5-10% reductions for awhile. Do whatever works best for you, realizing that you are going to inevitably experience some symptoms.
4. Individual variation
Most people fail to understand that one person’s experience discontinuing Nortriptyline may be radically different compared to theirs. This is due to numerous individual factors such as: genetics, lifestyle, stress level, sleep quality/quantity, whether the person is taking any supplements, social support, and other medications that a person may be taking. If you are taking medications and/or supplements, these may buffer or mask withdrawal symptoms from Nortriptyline.
Some people may also have more favorable genetics that allow them to adapt more quickly upon withdrawal from this medication. Those that eat nutritious foods, engage in exercise, get sunlight each day, have social support, get proper sleep, are taking supplements, and staying busy tend to recover quicker from withdrawals than those who engage in unhealthy activities (e.g. smoking, drinking, staying up all night, etc.).
Nortriptyline Withdrawal Symptoms: List of Possibilities
Keep in mind that discontinuation symptoms resulting from Nortriptyline (Pamelor) will differ in both quantity and severity based on the individual. Therefore it isn’t recommended to compare your symptoms to others. Most common symptoms from Nortriptyline withdrawal include: dizziness, fatigue, irritability, and nausea.
- Anger: Many people will notice that they experience anger upon discontinuation. This may be due to lack of serotonin and/or norepinephrine to keep them mentally alert. The anger may be minor and transitory or severe and long-lasting. Do your best to productively cope with the anger when it surfaces by exercising, deep breathing, etc.
- Appetite changes: Some people end up experiencing a drop in appetite while taking Nortriptyline due to the fact that it can be stimulatory. The norepinephrine increase while taking the medication may decrease appetite. When a person discontinues, they may gain back some of the weight they lost while taking the medication. Vice versa also applies (those that gained weight on the med tend to lose weight when they discontinue).
- Cognitive impairment: If the medication helped you focus, organize your thoughts, or memories, you may experience the exact opposite when you discontinue. Many people report a mild degree of cognitive impairment from dosage reductions or quitting the drug. It can take awhile for the neurotransmission to stabilize and norepinephrine and serotonin stores to increase and cognition to normalize.
- Crying spells: Many people discontinue this drug and notice that they feel more depressed than ever. In part, this could be due to dealing with a temporary antidepressant-induced chemical imbalance. The chemical imbalance results in depressive feelings, emotional sensitivity, and an increased likelihood of crying spells. You may feel overly emotional about things that would’ve never made you cry in the past.
- Depersonalization: You may feel as if you are disconnected from your true or authentic self. It may feel as if you are a spectator in your own body or are perceiving your experience from an outside perspective. Almost as if an alien has captured your soul and you have become a robot. This is common to experience during withdrawal and will not be permanent. I’ve found that this may be more common among dual-reuptake inhibitors (those affecting both noradrenergic and serotonergic functioning).
- Depression: The depression that you experience during withdrawal may be a result of neurotransmitter chaos that ensues upon discontinuation, but it may also be a result of your original depressive symptoms. Most people experience a compounding of their depression when quitting an antidepressant – leading them to feel worse than prior to taking the drug. Fortunately the severity lessens over time.
- Diarrhea: Those taking the drug may experience constipation as a side effect, and upon discontinuation, a person may end up with diarrhea. While this may not be as common of a withdrawal symptoms as others, it is still worth mentioning.
- Dizziness: Among the most common symptoms of Nortriptyline withdrawal is that of dizziness. Nearly all antidepressants result in dizziness when discontinued, especially if you quit cold turkey. Those that quit cold turkey (especially from a high dose) will likely end up with more extreme dizziness. Do your best to cope with feeling dizzy and realize that it is a common withdrawal symptom.
- Fatigue: Since this drug is considered stimulatory and activating, especially at high doses, you may experience the polar opposite of high energy when you discontinue. This means you may feel fatigued, have low energy, and chronic lethargy. To cope with this symptom, push yourself to do even mundane tasks like cleaning the house, going for a walk, etc. Over time the fatigue will improve, but it does take time.
- Flu-like symptoms: It may feel similar to having the flu when you quit taking this drug, especially if you quit cold turkey. This means you may notice that you’re sweating, feeling nauseous, have a headache, feel dizzy, and may end up vomiting. Realize that just like the actual flu, it takes time for your body to heal.
- Headaches: Another highly common withdrawal symptom that has been reported is that of headaches. You may experience more pronounced headaches if you discontinue cold turkey and/or from a high dosage. Stay hydrated, get plenty of rest, and try to engage in relaxation exercises as headaches are often exacerbated by tension and anxiety.
- Insomnia: For some individuals, Nortriptyline helped them get good sleep at night. Although the drug is activating, at certain doses it can affect histamine, which may help some people fall asleep at night. When the drug is stripped away or reduced in dosage, a person may end up dealing with insomnia. Various supplements like melatonin can be used to help combat this symptom.
- Irritability: Many people become irritable when they’ve fully discontinued this drug. It is difficult to cope with irritability as a result of withdrawal due to the fact that it is caused by neurotransmitter alterations. Assuming you are taking good care of yourself with diet, sleep, and supplements, the irritability should fade; expect gradual improvements.
- Lightheadedness: You may start to feel lightheaded throughout the day when you first begin withdrawal. The lightheadedness may be related to changes in blood flow, neurotransmission, and/or adjustments taking place in the nervous system. Realize that over time, the lightheadedness will improve.
- Mood swings: During withdrawal, it is common to feel exceptionally moody and have unpredictable moods. One moment you may find yourself feeling angry, the next extremely depressed, and the next you may feel hopeful. Realize that you may not be able to predict how you’re going to feel, but the rocky emotional “waves” should become calmer as time continues to pass.
- Muscle pain: This is a drug that can be taken to help a person cope with muscle pain, joint pain, neuropathic pain, and other low-grade pain. If you were taking it to help with pain, you may notice that the original pain returns and/or worsens upon withdrawal. Even if you weren’t taking it to treat pain, you may experience some soreness as your body readjusts to functioning without this drug.
- Nausea: It is very common to experience profound nausea when you quit taking Nortriptyline. This nausea may reduce your appetite or make you feel sick all day. In some extreme cases, it may actually lead to vomiting. Realize that the nausea will gradually fade in intensity over time, but will not improve overnight.
- Restlessness: You may find yourself unable to sit still, have pent up physical energy, and you may think that it’s impossible to relax during withdrawal. When you experience the restlessness, it is best to avoid resisting it, rather work with the energy. If you feel restless, make yourself go for a walk, ride your bike, or clean the house. Usually when we resist the restlessness is when it worsens.
- Sleep disturbances: Most people experienced sleep changes upon taking Nortriptyline, and when they discontinue, other sleep changes take place. If this drug helped you sleep, you may have a difficult time sleeping during withdrawal. If you weren’t able to sleep much while using the drug, you may find yourself sleeping in excess during withdrawal.
- Suicidal thoughts: For many people, returning depressive symptoms and a withdrawal symptoms lead a person to feel hopeless and experience suicidal thoughts. If you become suicidal, it is recommended to seek out professional help in coping with these thoughts. A psychotherapist is usually your best bet. Understand that increased suicidal thinking is common during withdrawal.
- Sweating: Discontinuing any antidepressant medication often results in excessive sweating. You may find yourself sweating more throughout the day or wake up in the middle of the night covered in a thick vat of sweat. Understand that some sweating is a means by which your body is detoxifying itself from the drug.
- Vomiting: In extreme cases, those that experience nausea may end up vomiting as a result. Nausea is a very common withdrawal symptom, and often precedes vomiting. If you cannot help vomiting, realize that it probably won’t be a long-lasting symptom. To minimize the likelihood that you’ll vomit, conduct a gradual taper.
- Weight gain: Some people end up losing weight from Nortriptyline as a result of its stimulatory effect. This means that their metabolism speeds up, they have a reduced appetite, and are more energetic while taking the drug. Upon discontinuation, you may end up gaining some of the weight back that you lost while on the drug.
Note #1: On average, nortriptyline stays in your system for nearly 6 days post-discontinuation. However, in some cases, it may linger for a longer duration (up to 21 days in certain users). Differences in plasma elimination of nortriptyline and its 10-OH-NT metabolites, usually result from CYP2D6 expression. As a result, there are interindivdiual differences in the onset times of withdrawal symptoms and their severity.
Note #2: Understand that you may experience discontinuation symptoms that may not have been mentioned above. If you would like to report another symptom that you’re certain is from withdrawal, share it in the comments section below.
Nortriptyline Withdrawal Duration: How long does it last?
Everyone wants to know exactly how long withdrawal from Nortriptyline will last. The problem with giving a specific answer is that it may be accurate for one person, but grossly inaccurate for another. One person’s withdrawal may take 2 weeks, while another person’s may take 2 months. A third person may end up experiencing post-acute withdrawals that last for 6 months.
Much of the withdrawal duration has to do with the factors mentioned above such as: time span and dosing. A person who took the drug for 10 years at the highest dose will likely have more pronounced withdrawal symptoms than someone who took the drug for 3 months at the lowest dose. It is important to avoid getting caught up in “how long” symptoms will last and instead focus on doing what you can (what’s in your power) each day to expedite recovery.
As a rule of thumb, I recommend waiting at least 90 days (3 months) before judging as to whether you’ve improved in these symptoms. Yes 90 days is quite awhile, but that’s how long it can take before the severe symptoms start to fade. Recovery may be expedited if you are getting proper sleep, eating healthy, taking the right supplements, staying busy, socializing when possible, and getting sunlight.
Have you experienced Nortriptyline withdrawal?
If you’ve been through Nortriptyline withdrawal or are currently in the process of discontinuing this drug, feel free to share your experience in the comments section below. Understand that by sharing your experience, you may help someone who is going through something similar. To help others get a better understanding of the specifics, you may want to share the dose from which you discontinued, how long you were on the drug, and other symptoms that may not have been mentioned above.