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Key takeaways
Gabapentin and nortriptyline are both prescription medications frequently prescribed off-label for nerve pain relief.
Gabapentin works more quickly, but may cause drowsiness.
Nortriptyline is a less expensive medication that can be risky for patients with heart problems, but has been shown to treat nerve pain effectively.
Often known as neuropathic pain, nerve pain is a mild to severe pain that occurs due to damage or injury to the nerves. Two of the most common medications used to treat nerve pain are gabapentin (brand names Horizant, Gralise, and Neurontin), a prescription anticonvulsant, and nortriptyline (Aventyl, Pamelor), a tricyclic antidepressant (TCA). Each drug works differently and can come with unique side effects. Understanding how these drugs work and the potential side effects can help you decide whether gabapentin or nortriptyline is the best medication for your needs.
What is gabapentin?
Gabapentin is a prescription anticonvulsant that was originally developed as an anti-seizure medication to prevent and control partial seizures. However, it is also often prescribed off-label for nerve pain, particularly for people with postherpetic neuralgia caused by shingles.
Known as a gamma-aminobutyric acid (GABA) analogue, gabapentin works to mimic the way that GABA reduces the activity of neurons in the brain, calming overactive signals that can cause seizures. By reducing the activity of nerve cells in the brain, gabapentin is also able to help reduce nerve pain by attaching to certain calcium channels in the brain and spinal cord, reducing the release of signals that trigger pain and making it a go-to option for people with neuropathic pain, specifically adults with chronic neuropathic pain from diabetes, shingles, or even injuries.
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Gabapentin dosages can vary by individual and should be prescribed by a healthcare provider. The prescription drug is available as a tablet, capsule, and oral solution, and may range anywhere from 50 to 600 milligrams (mg). Typically, gabapentin can be taken up to three times daily, and providers may gradually increase dosage as needed, depending on the individual’s kidney function. It’s common for some people to take 300 mg of gabapentin three times per day, but high doses of up to 1200 mg three times daily are possible. Ultimately, dosing should be left to the discretion of your healthcare provider.
While gabapentin can be highly effective in treating nerve pain, there’s no guarantee that it will eliminate all nerve pain. “The medication offers significant relief from nerve pain, but cannot always eliminate it,” says Shana Johnson, MD, a board-certified physician in physical medicine and rehabilitation specializing in chronic pain of AskDrShana Physical Medicine and Rehabilitation in Scottsdale, Arizona.
Often, gabapentin is used as a part of a person’s treatment method alongside other medications and therapies to target nerve pain holistically.
What is nortriptyline?
Nortriptyline is a tricyclic antidepressant (TCA) that is also used to treat nerve pain. Although it is primarily used in people with depression to boost serotonin production in the brain, it has also been found to be effective in treating neuropathic pain and is often prescribed off-label for such cases.
“[Nortriptyline] helps with nerve pain by increasing certain brain chemicals, mainly norepinephrine and serotonin, that help reduce how strongly we feel pain,” says Harold Hong, MD, MBA, a board-certified psychiatrist and medical director with New Waters Recovery in Raleigh, North Carolina. “In addition, it can slightly block certain nerve signals, which adds to its pain-relieving effects.”
Nortriptyline, when used to treat neuropathic pain, is typically started at an initial dose of 10 mg daily and may be gradually increased to 75 mg daily. It is usually given as a single dose at night time, to reduce any sedative effects during the day. Your healthcare provider can help determine your daily dosage and dosing schedule.
How do they compare?
While both gabapentin and nortriptyline can help treat neuropathic pain, they work differently, and some people will respond better to one than the other.
One of the most significant differences between the two drugs is their onset of action. “Gabapentin tends to act more quickly,” Dr. Hong says. “Patients often notice some relief within a few days to a week. Nortriptyline typically takes two to three weeks before full benefits are felt. So, if someone needs faster relief, gabapentin might be the better choice to start.”
There can also be price differences between the two drugs. Gabapentin’s price often exceeds that of nortriptyline, but it’s essential to discuss your options with your healthcare provider and consult your insurance provider to determine what is covered under your plan.
Gabapentin and nortriptyline are each associated with unique side effects, which should be taken into consideration before beginning either medication.
Below is a breakdown of the possible side effects of gabapentin and nortriptyline:
Side effects of gabapentin vs nortriptyline |
|
|---|---|
| Gabapentin | Nortriptyline |
| Drowsiness
Dizziness Fatigue Swelling Weight gain Changes in mood Suicidal thoughts or actions Anxiety Confusion Decreased coordination Low blood sugar Nausea Vomiting Difficulty breathing Dark urine |
Dry mouth
Dry eyes Constipation Weight gain Dizziness Blurred vision Drowsiness Low blood pressure Changes in heart rhythm Sensitivity to the sun Anxiety Agitation Suicidal thoughts or actions |
Both gabapentin and nortriptyline may interact negatively with other drugs. If you’re taking any of the following medications, please consult with your healthcare provider before using them in combination with gabapentin or nortriptyline:
Gabapentin and nortriptyline interactions |
|
|---|---|
| Gabapentin | Nortriptyline |
|
|
Gabapentin vs. nortriptyline warnings
When choosing the most effective drug for treating nerve pain, it’s important to consider the possible risks associated with each medication.
“[Gabapentin] can make you feel extra drowsy if taken with alcohol or sedating drugs.” Dr. Hong explains. He also notes that gabapentin should be used carefully in patients with kidney problems, as gabapentin is cleared through the kidneys and can build up if they’re not working properly. If mood changes occur while taking gabapentin, the dose may need to be adjusted.
Depending on the individual, taking nortriptyline can be a bit riskier. Tricyclic antidepressants have a side-effect profile that limits their use. “They are not a good choice for people who have heart disease, complex medical conditions, decreased memory, or in older adults,” Dr. Johnson says. “Anticholinergic medications are not good for brain health over the long term, so their duration of use is limited.” Nortriptyline should not be used by patients who have recently had a heart attack, and should be used cautiously in people with a history of seizures, heart rhythm problems, liver disease, or certain mental conditions like bipolar disorder.
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Which one is right for you?
Ultimately, the decision between the use of gabapentin or nortriptyline for nerve pain comes down to the discretion of each person and their healthcare provider.
Both drugs are effective for treating nerve pain, but they will not work for everyone. People taking gabapentin may experience more drowsiness and changes in mood, while those taking nortriptyline may face dry mouth, constipation, and blurred vision. However, just because you experience side effects does not necessarily mean you are taking the wrong medication–it may just mean that your dose needs to be adjusted.
Finding the right medication is a process of trial and error. If the first medication you try doesn’t seem to be effective, your healthcare provider may recommend switching to a different medication. However, it is important to always follow up with a healthcare provider before suddenly stopping a medication, as doing so unsupervised can be dangerous for your health.
- Neurontin, AccessFDA (2017)
- Gabapentin, Cleveland Clinic (2021)
- Gabapentin for chronic neuropathic pain in adults, National Library of Medicine (2017)
- Nortriptyline (oral route), Mayo Clinic (2025)
- Nortriptyline for the treatment of pain, The Dudley Group (2021)
- Nortriptyline for neuropathic pain in adults, Cochrane Database of Systematic Reviews (2015)
- Taking gabapentin with other medicines and herbal supplements, National Health Services (2022)
- Shana Johnson, MD of AskDrShana Physical Medicine and Rehabilitation
- Harold Hong, MD, MBA of New Waters Recovery