Pharmacotherapy options for nociplastic pain
| Drug class and medication | Predominant symptoms and dose | Potential side effects |
|---|---|---|
| Selective serotonin-norepinephrine reuptake inhibitors | Pain and depression | |
| Duloxetine | Start at 30 mg in morning; can increase to 60 mg daily in a few weeks as tolerated14 | Nausea, headache, diarrhea; do not stop suddenly—taper off gradually |
| Milnacipran | Start at 12.5 mg in the morning, increase by 12.5 mg every few weeks to 50–100 mg once or twice daily as tolerated14 | As above |
| Tricyclic antidepressants | Pain, sleep, fatigue, and overall quality of life | |
| Amitriptyline | Start at 5–10 mg 1 to 3 hours before bedtime; increase by 5 mg no more frequently than every 2 weeks; use lowest dose possible (20–30 mg)46 | Dry mouth, dry eyes, blurred vision, flushing, constipation, urinary retention, dizziness, drowsiness, cardiac arrythmia |
| Nortriptyline | Start at 10 mg at bedtime; up to 75 mg maximum46 | Like amitriptyline but preferred due to fewer anticholinergic side effects |
| Alpha 2 delta ligands | Prominent sleep disturbance | |
| Pregabalin | Start at 25–50 mg at bedtime; increase by 25–50 mg every 2 to 4 weeks to 300–450 mg daily (in 1 or 2 divided doses) as tolerated14 | Dizziness, drowsiness, peripheral edema, weight gain, blurred vision |
| Gabapentin | Start at 100 mg at bedtime; increase by 100 mg every 2 to 4 weeks to 1,200–2,400 mg daily (usually in 2 or 3 divided doses) as tolerated46 | As above |