(FDA approved in bold)

• Major depressive disorder
  
• Generalized anxiety disorder
  
• Fibromyalgia
  
• Diabetic peripheral neuropathic pain (PDN)
  
• Migraine prophylaxis
  
• Tension-type headache prophylaxis
  
• Other painful peripheral neuropathies
  
• Cancer pain (neuropathic)
  
• Stress urinary incontinence

• Blocks serotonin and noradrenergic reuptake pumps, increasing their levels within hours, but antidepressant effects take weeks. Effect is more likely related to adaptive changes in serotonin and norepinephrine receptors systems
  
• Weakly blocks dopamine reuptake pump (dopamine transporter)

• Fibromyalgia – as little as 2 weeks, but may take up to 3 months
  
• Migraine – effective in as little as 2 weeks, but can take up to 10 weeks on a stable dose to see full effect
  
• Tension-type headache prophylaxis – effective in 4–8 weeks
  
• Neuropathic pain – usually some effect within 4 weeks
  
• Diabetic neuropathy – may have significant improvement with high doses within 6 weeks
  
• Depression – 2 weeks but up to 2 months for full effect

• Fibromyalgia- the goal is to reduce pain intensity and symptoms, reduce use of analgesics and improve quality of life
  
• Migraine – goal is a 50% or greater reduction in migraine frequency or severity. Consider tapering or stopping if headaches remit for more than 6 months or if considering pregnancy
  
• Tension-type headache – goal is 50% or greater reduction of days with headache, duration or intensity. Consider tapering or stopping if headaches remit for more than 6 months or if considering pregnancy
  
• Diabetic neuropathy – the goal is to reduce pain intensity and reduce use of analgesics, but usually does not produce remission. Continue to monitor for AEs and maintain strict glycemic control
  
• Depression – continue to use and monitor for AE. May continue for 1 yr following first depression episode or indefinite if >1 episode of depression

• Increase to highest tolerated dose
  
• Fibromyalgia, migraine and tension-type headache: address other issues, such as medication-overuse, other coexisting medical disorders, such as anxiety, and consider changing to another agent or adding a second agent
  
• Neuropathic pain: either change to another agent or add a second agent

• Fibromyalgia: SNRIs such as milnacipran and/or AEDs, such as gabapentin, pregabalin, are agents that may be useful in managing fibromyalgia. May also use in combination with natural products and non-medication treatments, such as biofeedback or physical therapy, to improve pain control
  
• Migraine: For some patients, low-dose polytherapy with 2 or more drugs may be better tolerated and more effective than high-dose monotherapy. May use in combination with AEDs, antihypertensives, natural products, and non-medication treatments, such as biofeedback, to improve headache control
  
• Neuropathic pain: AEDs, such as gabapentin, pregabalin, carbamazepine, and capsaicin, mexiletine are agents used for neuropathic pain. Opioids are appropriate for long-term use in some cases but require careful monitoring

• Check blood pressure at baseline and when increasing dose