Panic Disorder Medications: How to Treat Panic Attacks

What Is Panic Disorder?

The most prominent feature of panic disorder is the occurrence of repeated panic attacks that may occur without a specific trigger. These attacks separate panic disorder from other types of anxiety disorders.²

A panic attack is best described as a moment, or spike, of increasingly intense anxiety that feels subjectively like fear, loss of control, and a sense of imminent doom. During incredibly severe episodes, individuals can authentically believe they will die from a panic attack. Understandably, people with attacks like these often seek emergency medical treatment.

After its onset, a panic attack’s uncomfortable physical and mental feelings peak within minutes. Still, they feel more long-lasting because the shock to a person’s system is so intense the effects of a panic attack can last hours before they can settle back into feeling normal again.

Individuals with untreated panic attacks may begin to engage in avoidant behaviors, steering clear of places and situations where an attack happened. For example, if someone has a panic attack in a public location (e.g. a restaurant or crowded train), they may increasingly avoid those spaces. For some, panic attacks occur so frequently when they leave their homes that they begin isolating themselves as they feel staying home is their only safe option.

Symptoms of a panic attack include:²

• Heart palpitations, pounding heart, or increased heart rate
• Sweating
• Trembling or shaking
• Sensations of shortness of breath or smothering
• Feelings of choking
• Chest pain or discomfort
• Nausea or abdominal distress
• Feeling dizzy, unsteady, light-headed, or faint
• Chills or heat sensations
• Numbness or tingling sensations

How Are Medications Used for Panic Attacks?

Treatment of panic disorder with medication and therapy primarily focuses on reducing a person’s overall or generalized anxiety level. If medicine can successfully achieve this, the anxiety characteristic of a panic attack is less likely to occur. It’s like putting a ceiling or cap on how high someone’s anxiety can go so that there is no room for the spike of a panic attack to happen.

Taken consistently, antidepressants alone can limit or even eliminate panic attacks, especially in combination with focused therapy. Should panic attacks persist while someone is taking an antidepressant solely, prescribers can add faster-acting medications alongside the antidepressant to get better control over the attacks.

Antidepressants for Panic Disorders

Antidepressant medications can make you feel better by increasing mood and reducing anxiety in people whose functioning is limited by depression, insomnia, excessive worry, and panic attacks. In general, antidepressants are well-tolerated and safe when taken daily.

Antidepressants usually take between four and six weeks to work and reach optimal effect, but it is essential to know that symptoms may improve much more quickly than this. Many people report improvement within the first two weeks of taking an antidepressant. The best results in symptom resolution require the proper treatment duration and the appropriate dosage.³

These medications have a black box warning, the most severe kind of warning from the FDA for the risk of suicidal thoughts and behaviors in certain people. You should talk with your doctor about these risks before starting these medications.

Selective-Serotonin Reuptake Inhibitors (SSRIs)

Selective-serotonin reuptake inhibitors (SSRIs) work by blocking neurons in the brain from reabsorbing serotonin, leading to an increased level of neurotransmitters in the brain’s synapses. Increasing the amount of available serotonin has been shown, over time, to raise mood and reduce anxiety symptoms. SSRIs can also improve sleep, appetite, concentration, and energy levels to restore pleasure to people’s daily activities.

Each SSRI reaches its therapeutic level at different amounts of a total daily dose. The critical thing to focus on is not the dosage you are receiving, which can range from 5mg up to 200mg, but how well the particular treatment dose reduces the target symptoms you are experiencing.

Importantly for this article’s purposes, several SSRI antidepressant medications are indicated for the treatment of panic disorder. Others are used as off-label medications (not FDA-approved) to treat the diagnosis.

SSRI antidepressants are considered first-line options for the treatment of diagnoses, including:

• Major depressive disorder (MDD)
• Generalized anxiety disorder (GAD)
• Obsessive-compulsive disorder (OCD)
• Panic disorder

After diagnosing one of these conditions, if a doctor believes medication management is indicated, they will usually prescribe an SSRI to be taken once daily in the morning.

SSRIs that are FDA-approved for the treatment of panic attacks/disorders include:

• Prozac (fluoxetine)
• Zoloft (sertraline)
• Paxil (paroxetine)

SSRIs used as off-label medications for the treatment of panic attacks/disorders include:

• Lexapro (escitalopram)
• Celexa (citalopram)

Common side effects of SSRIs include:⁴

• Anxiety symptoms
• Insomnia
• Dry mouth
• Sexual problems
• Nausea
• Diarrhea
• Dry mouth

Serotonin-Norepinephrine Reuptake Inhibitors (SNRIs)

While not nearly as popular as SSRIs in treating conditions like MDD, GAD, OCD, and panic disorder, SNRI antidepressants are also effective in managing symptoms of these diagnoses. SNRIs are also taken once daily in the morning.

Despite having similar mechanisms of action, the difference between SSRIs vs. SNRIs is that, alongside increasing serotonin levels, SNRI medications also increase levels of norepinephrine at brain synapses. Increased levels of norepinephrine have been shown to improve energy, attentiveness, and the sleep/wake cycle. Norepinephrine also inhibits the “fight-or-flight” response when an especially frightening or dangerous situation confronts us.

Increasing the levels of both serotonin and norepinephrine with an SNRI can produce a more robust response in some individuals who do not respond well enough to an SSRI. The typical dosing range for SNRIs is similar to that for SSRIs.  The only SNRI that is FDA-approved for the treatment of panic disorder is Effexor (venlafaxine).

Examples of SNRIs used as off-label treatments for panic attacks/disorders include:

• Cymbalta (duloxetine)
• Pristiq (desvenlafaxine)
• Fetzima (levomilnacipran)

Common side effects of SNRIs include:⁵

• Headache
• Nausea
• Insomnia
• Weight changes
• Dizziness

Monoamine Oxidase Inhibitors (MAOIs)

The MAOIs are an older class of antidepressant agents. SSRIs and SNRIs have largely replaced their use in treating depression and anxiety. This shift from MAOIs is due to their high prevalence of adverse drug and food interactions that can result in both serotonin syndrome and hypertensive crisis when taken together. Importantly, MAOIs cannot be taken simultaneously as an SSRI or SNRI, and therefore are rarely used in treatment for mood and anxiety disorders. Before starting another medication, a wash-out period is required to clear either drug from your system. Treatment of panic disorder with MAOIs is not an FDA approved use of the medication.

MAOIs are thought to work by blocking the action of monoamine oxidase (MAO), the enzyme that prevents neurotransmitters (serotonin, norepinephrine, and dopamine) from being active in the brain. As discussed above, an overall increase in these neurotransmitters has been shown to reduce symptoms of depression and anxiety. In today’s prescribing landscape, specialists will reserve them for the treatment of atypical depression and treatment-resistant depression.⁶

MAOIs used off-label to treat panic attacks/disorders include:

• Nardil (phenelzine)
• Parnate (tranylcypromine)
• Emsam (selegiline transdermal)
• Marplan (isocarboxazid)

Common side effects of MAOIs include:⁵

• High blood pressure
• Tingling skin
• Dizziness
• Headache
• Drowsiness
• Sleep disturbance
• Tremors

Tricyclic Antidepressants (TCAs)

Tricyclic antidepressants (TCAs), like the MAOIs, are an older family of antidepressants that are no longer widely prescribed for depression or anxiety. They are as effective as the newer agents but have more extensive and limiting side effect profiles and have a potential for cardiac toxicity. Additionally, TCAs can have a lethal overdose effect which carries a higher risk if given to suicidal individuals. TCAs take approximately four weeks to work optimally. Given their increased risks, TCAs are not FDA-approved to treat panic disorder and thus are considered an off-label medication.⁷

TCAs used off-label to treat panic attacks/disorders include:

• Elavil (amitriptyline)
• Pamelor (nortriptyline)
• Sinequan (doxepin)
• Norpramin (desipramine)

Common side effects of TCAs include:⁵

• Drowsiness
• Dry mouth
• Dizziness
• Constipation
• Blurred vision
• Palpitations
• Tachycardia

Antianxiety Medications

Antianxiety medications, or anxiolytics, are probably the most effective treatment for panic attacks. They are much faster-acting than antidepressants and, more specifically, target symptoms of generalized anxiety disorder and panic disorder. Of the classes discussed below, benzodiazepines are the most commonly used medication to stop a panic attack during the height of symptoms. All benzodiazepines are controlled substances and should be used in moderation and only over short periods. Medical professionals prescribing benzodiazepines should be highly selective because they all come with diversion, abuse, and dependence risks.

These medications have a black box warning, the most severe kind of warnings from the FDA for abuse or misuse, risk of physical dependence, and risk of severe side effects, including death, when combined with an opioid.

Benzodiazepines

Benzodiazepines belong to the larger category of sedative-hypnotics. They work in the body by binding to receptors for gamma-aminobutyric acid (GABA), the major excitatory neurotransmitter in the central nervous system. Benzodiazepine binding to GABA receptors decreases GABA transmission, thus dampening its excitatory effect and reducing the anxiety associated with increased levels of GABA. In other words, benzodiazepine work by slowing down an already overly excited nervous system.⁸

Benzodiazepines should be used alongside longer-acting medications (preferably an SSRI or SNRI) to treat panic disorder. They can be prescribed on a standing or as-needed (PRN) basis. The decision between standing and PRN dosing is based on the speed with which the particular benzodiazepine works and how long the therapeutic effect lasts.

Isolated panic attacks triggered by flying in an airplane or medical procedures are best treated with shorter-acting benzodiazepines like Xanax or Ativan on a PRN basis. Whereas chronic panic attacks, especially those that occur without a trigger, may require standing doses of a long-acting benzodiazepine like Klonopin for a set period.

All benzodiazepines have withdrawal symptoms if abruptly stopped after being used for an extended time. Severe benzodiazepine withdrawal can result in seizures, respiratory depression, and death.⁹

Benzodiazepines that are FDA-approved for the treatment of panic attacks/disorder include:

• Klonopin (clonazepam)
• Xanax (alprazolam)

Benzodiazepines used off-label to treat panic attacks/disorders include:

• Ativan (lorazepam)
• Valium (diazepam)

Common side effects of Benzodiazepines include:

• Mental fatigue
• Slurred speech
• Sedation
• Dizziness
• Ataxia
• Respiratory depression
• Hypotension
• Amnesia

Beta-Blockers

Beta-blockers work by blocking catecholamine neurotransmitters (dopamine, norepinephrine, and epinephrine) from binding to beta receptors in the body. When these neurotransmitters activate beta receptors, it causes a fight-or-flight response leading people to experience physical symptoms such as an increased heart rate, sweating, and shaking.

These symptoms overlap with those that occur during a panic attack. Using a beta-blocker for panic disorder is not preventative but can reduce the intensity of the symptoms once they occur.

Beta-blockers are FDA-approved for treating high blood pressure, angina, and cardiac arrhythmias, among other conditions but are not approved for use in anxiety disorders such as panic disorder and are considered off-label. They are most effective in cases of social anxiety disorder, especially fear of public speaking.

Beta-Blockers used off-label to treat panic attacks/disorders include:

• Inderal (propranolol)
• Tenormin (atenolol)
• Coreg (carvedilol)
• Trandate (labetalol)
• Toprol (metoprolol)
• Brevibloc (esmolol)

Common side effects of Beta-Blockers include:¹⁰

• Low blood pressure
• Depression
• Dizziness
• Constipation
• Insomnia
• Weakness

BuSpar & Neurontin

BuSpar (buspirone) and Neurontin (gabapentin) are two other medications that may be used to treat panic disorder. These medications, like antidepressants, are given to reduce someone’s overall anxiety level. The goal here is to prevent anxiety from rising to the level where a panic attack may arise.

Busprione is an anxiolytic agent used on-label for treating GAD and as an augmentation agent for treating MDD. Its use in treating panic disorder is off-label.  The drug works by increasing the availability of norepinephrine and dopamine in the brain.¹¹ Buspirone side effects can also develop, ranging from mild to serious.

Neurontin works by decreasing the release of excitatory neurotransmitters. Its use in treating anxiety is off-label.¹²

Side effects of buspirone include:¹¹

• Dizziness
• Drowsiness
• Nausea
• Headache
• Nervousness

Side effects of Neurontin include:¹²

• Dizziness
• Somnolence
• Unsteady gait
• Fatigue
• Fever

Natural Remedies

Naturally occurring substances and supplements are also used to treat anxiety and, by extension, panic disorder. These supplements are available to buy in supermarkets and drugstores.

These include but are not limited to the following:

• St John’s Wort
• Magnesium
• Saffron
• Vitamin D
• Chamomile

Dietary supplements (including vitamins, supplements, herbs, and natural medicines) are not regulated the same way as medications by the FDA. Before being sold to the public, these products do not have the same clinical trials to determine their safety and efficacy. You should consult your doctor or pharmacist before starting any new dietary supplement.

How to Choose the Best Panic Attack Medication for You

If you think you might have a panic disorder, the first step in getting the proper medication is to seek evaluation by a medical professional. Psychiatric evaluation is optimal since psychiatrists are more well-versed in assessing and diagnosing panic disorders. Still, a primary care provider or other specialists can undoubtedly do a thorough enough assessment to determine whether the diagnosis is possible or even probable.

Any evaluation for panic disorder should include a complete medical, social, and family history assessment. Co-occurring general medical conditions can sometimes result in anxiety symptoms, and treating the underlying medical condition may prevent the need for psychiatric medication.

Important contributing information from your social history might include stressful life events causing acute and hopefully short-lived symptoms. Family history is crucial because it is well-known that genetic factors significantly predispose someone to any form of mental illness.

Once a medical professional confers a diagnosis of panic disorder, medication management may be recommended. Once undertaken, treatment with medication can take time and include trial and error before the most effective drug is found. Tolerance and lack of efficacy can necessitate changes between medicines in each class or between classes.

Additional Treatments Alongside Panic Disorder Medication

While medication management for the symptoms of panic disorder can be pretty effective on its own, the addition of psychotherapy alongside the medication can improve outcomes even more. The different modalities of psychotherapy for panic disorder aim to identify underlying thought processes that cause panic attacks, to help individuals recognize these thoughts, and to alter responses to prevent the attacks from occurring.

Therapy can also provide individuals with healthy coping mechanisms to minimize a panic attack’s physical and emotional symptoms. Finding the right therapist for you will take some consideration and possibly some trial and error, but using an online therapist directory can take out most of the guesswork when considering their specialty and mental health insurance coverage.

Therapy options for panic attacks/disorders include:

• Cognitive Behavioral Therapy (CBT): CBT techniques for panic disorder focus on psychoeducation, relaxation techniques, and exposure therapy, among others.¹³

• Group therapy: Group therapy can benefit those with panic disorder by allowing them to learn from the varying experiences of others with the diagnosis in a supportive environment.

• Guided meditation: Meditation sessions, which can be pre-recorded, done through a meditation app, or in person, help raise awareness of how anxiety feels in the body and mind and teach the patient how to change their response to triggers. Altered responses can prevent a panic attack and minimize symptoms during the panic attack itself.¹⁴

• Eye movement desensitization and reprocessing (EMDR): EMDR is most often used to treat PTSD, but studies have shown it can be effective for treating panic attacks. As the name suggests, this therapy uses eye movement like that seen in REM sleep to replace a negative belief with a positive one.¹⁵

• Panic-focused psychodynamic therapy (PFPP): PFPP is a three-phase manualized adaptation of traditional psychodynamic therapy focusing specifically on panic attacks. The initial phase aims to relieve panic symptoms; the second phase involves the patient identifying core conflicts that contribute to panic attacks; the third phase is termination with the therapist.¹⁶

Questions to Ask Before Beginning a New Medication

Nobody should accept a prescription or treatment from a medical professional without doing due diligence to gather information first. No medicine will be an entirely benign thing to put in your body. Every medication comes with the potential for multiple side effects. A sensible approach is to ask questions about how the medicine will help and what risks you might have.

Before beginning medication for panic disorder, consider asking your doctor/psychiatrist the following questions:

• What condition is the drug being used to treat?
• How long will the medicine take to work?
• How long do I need to take the medication?
• What are some of the side effects of the drug?
• If this medication doesn’t work, are there alternatives?

Final Thoughts

Panic disorder is scary, and panic attacks themselves feel bewildering. Thankfully, many treatments are available to help you understand what’s happening to you when a panic attack occurs and reduce or eliminate the chances of additional panic attacks. Still, you will need patience as even in the hands of a medical professional with experience treating panic disorder, it will take time to find the proper treatment for your needs. Once you reach this goal, you will experience relief from your symptoms and better overall well-being.