Comparison of Venlafaxine and Amitriptyline

As a comparison, I saw significant benefits from Amitriptyline within 3 days! Within 2 weeks that was very significant. (Still not silver bullet though: it all but eliminated migraines but not vestibular attacks). Appreciate it’s very personal.

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One of the tricyclics is next for me if this doesn’t work out. I think Effexor is slightly favored over here by doctors due to the comparatively good side effect profile


Depends which doctor you speak to? Venlafaxine is harder to wean off of.

The only lasting (whilst on med) side effect for me was slow bowel. My friend on venlafaxine had that so bad she ended up having a gastroscopy! (An entirely unnecessary one I might add: the doctor was clueless about SNRI’s) So pick your poison!

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statistically, tricyclics have a significantly worse side-effect profile. I’ve heard that weaning off venlafaxine is hard, but its nothing compared to more addictive substances like benzos and opioids. probably the most extreme ssri/ssnri drug withdrawal

venlafaxine is probably more uncomfortable but none of the side effects are potentially medically dangerous. tricyclics are probably easier on the patient’s experience of the drug, but there is appreciable risk of cardiac side effects, and weight gain.

they are probably very even overall when it comes to a side by side comparison, but based on everything i’ve read so far, venlafaxine is clean when it comes to side effects and might be slightly more effective, but it all depends on the individual.

pick your poison sounds right!

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Source please. I think that’s a very controversial statement.

Tricyclics are extremely old, so there’s a lot of experience with them and generally well tolerated.

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Tricyclics are first generation antidepressants. Although effective, we developed other drug classes down the road because of the side effect profile


Couple of issues with that source:

  1. This is about vestibular health, not depression!! Tricyclic anticholinergic effects (marked here as a ‘side effect’) are often desirable in patients with dizziness as they constitute a vestibular suppressant. This aspect was very helpful for me. The “cardiotoxic SE” have been recognised for a long time and as such those drugs are not prescribed to people who are susceptible to that issue. Nausea SE is dubious as reported here: Amitriptyline is often prescribed precisely to get rid of the nausea and it was excellent in this respect for me. Most importantly: you don’t take TCA in anything like the doses you do for depression (e.g. ~20mg nocte versus ~10x for depression!!), so a lot of these “issues” are a complete non-issue! (especially when you get used to the drug after a few months).

  2. The list of SE’s for SNRI’s therefore appears longer?

James I think you’re misunderstanding what I’m trying to say. When physicians prescribe these medications, they’re balancing risk and reward.

It’s not about which side effect list is longer or shorter but rather which drug has the highest potential return on investment for the lowest danger to the patients health. It’s not even about which drug has the best experience for patients (all you have to do is look at the reviews for both of these drugs to figure out which is the clear favorite, and it’s not venlafaxine)

These drugs are all used off-label for MAV, so unfortunately most if not all the literature for side effect profiles has to do with what the drugs were originally approved for. You can do a literature search yourself and come up with the same conclusion.

I’m thrilled for you that you had such a good response to amitriptyline, but here I’m talking about the complete ensemble of data instead of individual experiences.

When it comes to physicians preference of Effexor over tricyclics, it’s probably because they have equal efficacy while the (small) risk for potential dangerous side effects do not exist. That’s all I’m saying. It’s a risk calculation that slightly favors venlafaxine, but if patients experience dictates otherwise, they can easily just use the other drug.

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But your “data”(?) is for “depression”

What risk ‘calculation’? I see no calculation here for patients suffering with vestibular complaints.

I’m also not saying that one drug is better than the other! More to explain why physicians have preferences of one over the other.

I wanted to start with Nort, but I was told no. I understand why, but that was my preference

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As I explained, the literature is sparse for off-label use, but if you want data spelled out in the gold standard of drug-comparison, you can see the below randomized trial which discusses my exact point that although same in efficacy, venlafaxine has a slightly better side effect profile when it comes to comparison against TCA.


But this is not migraine, this is at best “vestibular migraine”, which is not the same thing! The vestibular aspect cannot be ignored. They may have completely different aetiologies.

The dosages are the same. I really don’t know what to tell you other than to dig around for yourself. You seem to have a really heavy bias towards amitriptyline because you’ve been on it, which is great. Again I’m happy for you.

It’s okay that amitriptyline has a worse side effect profile! That’s not taking away from your experience nor is it saying that it’s a worse drug! It’s just something that has to be considered when a prescription is written

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I’m concerned at you saying things like this:

without data. Taking ~30mg of amitriptyline is very unlikely to be risky!

I sourced the data. You just didn’t like the source.

If 30 mg is unlikely to cause side effects i actually think the onus is on you now to produce data that backs that claim up.

30 mg is a dose that’s close to the one that was included in the clinical trial that I referenced, and it had a higher adverse effect rate.

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Because it’s totally inappropriate for the level of dosage involved and the condition it’s treating.

It’s completely appropriate to use a side effect profile that was developed through clinical trials for prescription decision making, even if it was for another disease. The second source I listed includes the dose range that you want, which is 25 mg and still had a higher side effect rate.

I’m not responding to this topic anymore and requests to cherry-pick data, because I think the literature stands for itself!

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That’s not how I see it. Whilst the dosages of the second reference are much more inline with treatment for MAV/VM, again, it mentions the SF due to anticholinergic effects, which as I pointed out are actually a potential benefit for vestibular patients…

I’m not arguing that Venlafaxine can’t be effective for people, and I’m not suggesting that Amitriptyline is the better drug, but I’d like to see a directly applicable study for MAV/VM specifically. It surely must exist, because I agree, that many US doctors seem to favour Venlafaxine (but sometimes medicine goes through fashions …). My main concern was your statement “statistically, tricyclics have a significantly worse side-effect profile”. If data exists for that against benefits of symptom reduction (because that really matters too) all round for MAV/VM then please share that.

Let’s take a break from this debate, the topic will automatically re-open.

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