From the Guidelines
Several medications besides duloxetine can help improve both mood and pain, with venlafaxine (Effexor) at doses of 150-225mg daily being a recommended option. Other SNRIs (serotonin-norepinephrine reuptake inhibitors) like milnacipran (Savella) at 50-100mg twice daily are also effective options 1. Tricyclic antidepressants such as amitriptyline (10-75mg at bedtime) and nortriptyline (10-75mg at bedtime) also work for both conditions, though they have more side effects. Some atypical antidepressants like mirtazapine (15-45mg at bedtime) can help with both mood and pain while also improving sleep. These medications work by increasing levels of neurotransmitters like serotonin and norepinephrine in the brain and spinal cord, which helps regulate both mood and pain signals. The dual action on these neurotransmitter systems makes them particularly useful for conditions where depression and pain coexist, such as fibromyalgia, diabetic neuropathy, or chronic back pain. Most of these medications take 2-6 weeks to reach full effectiveness for both mood and pain relief, and should be started at lower doses and gradually increased to minimize side effects.
Key Points
- Venlafaxine (Effexor) is a recommended option for improving both mood and pain, with a dose range of 150-225mg daily 1.
- Milnacipran (Savella) at 50-100mg twice daily is also an effective option for improving both mood and pain.
- Tricyclic antidepressants like amitriptyline and nortriptyline can be used, but have more side effects.
- Atypical antidepressants like mirtazapine can help with both mood and pain, as well as improve sleep.
- These medications should be started at lower doses and gradually increased to minimize side effects.
Medication Options
- Venlafaxine (Effexor): 150-225mg daily
- Milnacipran (Savella): 50-100mg twice daily
- Amitriptyline: 10-75mg at bedtime
- Nortriptyline: 10-75mg at bedtime
- Mirtazapine: 15-45mg at bedtime
Important Considerations
- These medications can take 2-6 weeks to reach full effectiveness for both mood and pain relief.
- Starting at lower doses and gradually increasing can help minimize side effects.
- Conditions like fibromyalgia, diabetic neuropathy, or chronic back pain may benefit from these medications due to their dual action on mood and pain signals.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Medications for Mood and Pain Management
Besides duloxetine (Cymbalta), several other medications are available that can improve both mood and pain. These include:
- Tricyclic antidepressants (e.g., amitriptyline, nortriptyline, desipramine) 2
- Novel antidepressants (i.e., bupropion, venlafaxine) 2
- Milnacipran, which has shown promise in treating chronic pain, particularly fibromyalgia 3
- Gabapentinoids (e.g., gabapentin, pregabalin), which are effective in treating neuropathic pain and have modest efficacy in patients with fibromyalgia 2, 4
- Selective serotonin and noradrenaline reuptake inhibitors (SSNRIs), such as venlafaxine extended-release (XR) 5
Mechanism of Action
These medications work by modulating pain transmission through various mechanisms, including:
- Interacting with specific neurotransmitters (e.g., noradrenaline, serotonin) 4
- Inhibiting calcium currents and decreasing excitatory transmitter release 4
- Activating the descending noradrenergic pain inhibitory system coupled to spinal α2 adrenoceptors 4
- Indirectly acting as anti-proinflammatory cytokine drugs 4
Efficacy and Safety
The efficacy and safety of these medications vary, with some having more robust evidence than others. For example:
- Duloxetine has moderate- to high-certainty evidence for its efficacy in treating chronic pain, particularly neuropathic pain and fibromyalgia 6, 3
- Milnacipran has lower certainty of evidence, but shows promise in treating chronic pain, particularly fibromyalgia 3
- Gabapentinoids have documented efficacy in treating neuropathic pain, but their safety profile differs from that of antidepressants 2, 4