Post-Herpetic Neuralgia Prevention and Treatment with Nortriptyline

Introduction to Nortriptyline Therapy

• For patients with established post-herpetic neuralgia, the American Academy of Neurology recommends continuing nortriptyline indefinitely until pain relief is achieved, as post-herpetic neuralgia may persist for months to years 1
• Nortriptyline is preferred over amitriptyline due to superior tolerability with equivalent analgesic benefit, with a number needed to treat (NNT) of 2.64 1, 5

Dosing and Administration

• The initial dosing of nortriptyline should start at 10-25 mg at bedtime, with increases every 3-7 days as tolerated, targeting a dose of 25-100 mg at bedtime 2, 3, 4
• In elderly patients, it is recommended to start with lower doses (10 mg) and titrate more slowly to minimize side effects, according to the American Geriatrics Society 5

Treatment Duration and Outcome

• The treatment of established post-herpetic neuralgia may require indefinite continuation until pain resolves, as the condition can persist for months to years, with periodic reassessment recommended 1
• The probability of pain relief correlates strongly with the brevity of the interval between rash onset and antidepressant initiation, highlighting the importance of early treatment 1