Amitriptyline is a drug that physicians can prescribe for migraine therapy. While just a few trials have evaluated amitriptyline in migraine prevention or chronic daily migraine headache management, studies¹ reveal that amitriptyline is superior to placebo in preventing migraine headaches.
Research² further supports the widespread clinical practice of using low-dose amitriptyline to treat chronic migraine headache problems. Thus, it is effective, and people can tolerate it at lower dosages. Moreover, the use of low-dose amitriptyline may help enhance drug adherence, a critical therapeutic concern in the management of migraines.
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Amitriptyline is a tricyclic antidepressant (TCA). While doctors often prescribe TCAs for depression, many have alternative applications, like preventing migraines.
Medical professionals have used amitriptyline, in particular, to treat various chronic pain disorders, including migraine. Medical professionals generally use it to prevent migraines.
The use of amitriptyline to prevent migraine episodes is not new; research on this topic dates back to the 1970s, with researchers conducting a randomized controlled trial to determine its effectiveness. The studies³ concluded that amitriptyline helped prevent migraines.
Studies show that migraine is a neuropathic pain syndrome. Neuropathic pain refers to pain you would experience when you injure your nerves. Neuropathic pain is distinct from pain signals originating from damaged tissues. Pain from damaged tissues does not occur in the nerves but is instead carried through them.
Clinical medicine handles neuropathic pain differently from the pain that originates in damaged tissue. While common pain relievers such as paracetamol or ibuprofen are ineffective in most cases of neuropathic pain, medications meant to treat depression or epilepsy may be helpful for some people with neuropathic pain.
Amitriptyline increases the actions of neurotransmitters in the brain associated with mood and well-being, specifically serotonin and norepinephrine. Although activation of serotonin is important in the treatment of migraine, the role it plays is unclear. Some studies⁴ suggest that serotonin regulates blood vessels during a migraine headache or takes a role in the pain control pathways.
Amitriptyline's actions on serotonin levels help prevent migraine headaches, chronic tension-type headaches, and some other chronic pain conditions. Although research on amitriptyline's efficacy as a migraine preventative is limited, conducted trials¹ have shown it to be helpful
It is best to take amitriptyline in the evening or just before bed, as it can potentially make you dizzy. The medicine may take effect in one or two weeks, although it can take up to six weeks for amitriptyline to start working as preventative medicine.
Amitriptyline is available in the form of a tablet that you must swallow. The lowest effective dosage is ten milligrams (mg) per day; however, the medication is also available in higher doses per tablet. The AHS/AAN Guidelines for the Prevention of Episodic Migraines propose a daily dose of amitriptyline between 25 and 150 mg.
It may need some medication tweaking to determine the optimal dose for you. Your healthcare practitioner will likely begin with a very low dosage, wait several weeks for the medicine to get established in your system, then evaluate whether you need a larger dose. Your doctor is likely to consider how well you handle the amitriptyline and if it seems to be lessening your migraines.
Some individuals report feeling better within the first couple of weeks, in the case of migraines, and it can help immediately with insomnia problems.
However, it often takes at least four to six weeks before you see the full effect of amitriptyline for pain, migraine, or depression, so it's important to continue taking it even if it doesn't appear to be helping at first. Most patients will need continued amitriptyline treatment for many months after the first therapy.
Continue taking amitriptyline regularly until your doctor instructs you to discontinue. It takes up to six weeks of using the drug to adequately determine whether amitriptyline is helping with nerve pain, migraine, or tension headache. If your pain subsides, or you get fewer migraines or headaches, you may continue taking amitriptyline for as long as it assists.
Thus, your doctor may ask you to gradually reduce your dosage from time to time to see whether the issue persists and if it does, you may continue to take amitriptyline. Specific individuals take it for months, if not years.
It is inadvisable to abruptly discontinue taking amitriptyline without seeing your doctor since this might result in unpleasant symptoms, such as:
Loss of appetite
These symptoms are transient and are not related to drug addiction. They are typically avoidable by gradually discontinuing amitriptyline, usually over weeks or months. Depending on your specific case, when it is time to stop therapy, always follow your doctor's recommendations.
Interactions between drugs might alter how they operate or raise your chance of experiencing significant adverse effects. Maintain a list of all medications you take, including prescription or over-the-counter medicines and herbal supplements, and discuss it with your doctor and pharmacist.
Do not begin, stop, or modify the dose of any medication without your doctor's consent. Amitriptyline may interact with other medicines, raising your chance of experiencing adverse effects. Amitriptyline, in particular, may interact with opioid analgesics such as codeine, oxycodone, or morphine.
If pain medication is required, it is safe to combine paracetamol, aspirin, or ibuprofen with amitriptyline. However, it is advisable to avoid co-codamol, codeine, and other opioid pain medications, since they may exacerbate any sleepiness or constipation you may be experiencing.
Amitriptyline may potentially interact with another class of antidepressants known as monoamine oxidase inhibitors (MAOIs), resulting in dangerously elevated blood pressure. It may occur even after you have discontinued MAOI use.
Consult your doctor or pharmacist before taking amitriptyline about any medications you have taken or are now taking, including herbal remedies, vitamins, and supplements.
Patients respond differently to medications and associated side effects. Simply because a side effect is mentioned does not guarantee that everyone who takes this drug will experience it.
Consult your doctor if you are worried about side effects or suffer an unpleasant response to your medication. Amitriptyline may result in mild side effects, such as:
Drowsiness and dizziness
Constipation and weight gain
Headaches and sweating
Changes in appetite
Changes in sexual function
Amitriptyline may amplify the effects of alcohol. Even if you drink on occasion, be aware that the impact may be more potent than usual. Medical professionals don't recommend consuming large quantities of alcohol while on this medication.
Although severe side effects from taking amitriptyline are uncommon, they do occur. If you suffer any of the following while taking this medication, you should seek medical assistance immediately:
Fainting due to dizziness
Rapid, pounding, or irregular heartbeat
Severe skin rash or hives
Swelling of the face and tongue
Spasms of the jaw, neck, or back muscles
Weakness or numbness in a limb
Severe chest pains
Yellowing of skin or eyes
Unusual bleeding or bruises
If you experience significant symptoms while taking amitriptyline, you should immediately see a healthcare practitioner. Similarly, notify your healthcare provider if you have moderate side effects that worsen or do not resolve.
Amitriptyline is not addictive. However, abrupt discontinuation may result in adverse side effects. You may have flu-like symptoms such as nausea, muscular discomfort, fatigue, or restlessness. To avoid this, your doctor will likely suggest gradually decreasing your dosage over several weeks or longer if you have been taking amitriptyline for an extended period.
You can overcome side effects such as constipation by consuming more fibrous foods such as fresh fruit and vegetables and cereals. Remember to hydrate by drinking many glasses of water or other non-alcoholic beverages. Exercise may also be beneficial if you are able.
Consider using sugar-free gum or other sugar-free confectionery to reduce instances of dry mouth that can arise from amitriptyline.
While feeling fatigued is normal when using the drug, you can counter it by taking your medication in the evening. Amitriptyline can also leave you dizzy, mainly due to low blood pressure. You can overcome this by drinking lots of water. Also, avoid driving or using equipment while in this condition.
If you experience headaches, ensure that you get enough rest and consume lots of water. Avoid excessive alcohol consumption. If you need pain treatment, try paracetamol or ibuprofen. Consult your physician if your headaches persist for more than a week or are severe.
You can resolve difficulties when urinating by taking deep breaths. Do not attempt to force the urination process. If you are still unable to urinate, try again later. However, consult your physician immediately if you cannot urinate at all.
Amitriptyline comes with a Black Box warning from the FDA regarding its use among children, adolescents, and those under 24 years, as it can cause the development of suicidal thoughts or behaviors. However, adults over 24 years also have a negligible risk of suicidal thoughts or other mental health issues, particularly at the start of therapy or if the dose is changed.
According to a 2010 meta-analysis,⁵ tricyclic antidepressants significantly decreased the number of headache attacks associated with migraines and the number of days with tension-type headaches. Those with tension-type or migraine headaches were 40% to 70% more likely to report a 50% improvement in symptoms.
Additionally, the impact seemed to be cumulative since individuals treated for one month showed minor improvement compared to those treated for six months. In a limited number of comparison trials, amitriptyline was more effective than selective serotonin reuptake inhibitors in reducing headaches by 50%.
Tricyclic antidepressants such as amitriptyline seemed equally helpful in preventing tension-type, migraine, and mixed headaches. In addition, 2019 research⁶ found that amitriptyline has the highest proof of effectiveness among the antidepressants usually recommended to prevent migraine episodes.
Contraindications are vital issues to consider while providing medicine to a patient. The majority of individuals can take amitriptyline. Additionally, specialists may prescribe it off-label to alleviate nerve pain in children ages 2 to 17.
Physicians should be careful when administering amitriptyline to the following populations :
Patients with an irregular heartbeat or heart blockage
People who've recently had a heart attack
People with rare hereditary blood disorders
Patients in a manic phase of bipolar disorder
Individuals who are suffering from severe liver illness
Those using monoamine oxidase inhibitors (MAOIs) or have used them within the previous 14 days
Those on medications such as isocarboxazid that can raise serotonin levels when used with amitriptyline
Patients due to undergo elective surgery should also discontinue amitriptyline use due to the possibility of interaction with anesthetic drugs and an increased risk of arrhythmia.
Specific individuals, particularly the elderly, may need a lower amitriptyline dosage or more monitoring. Inform your doctor if you have any of the following conditions.
Possess an excessively active thyroid gland
Are taking thyroid medicine to treat hypothyroidism
Have an adrenal gland tumor (pheochromocytoma)
Have difficulties passing urine, for example, if your prostate gland is enlarged
Constipation for an extended period
History of increased intraocular pressure or glaucoma
Have epilepsy, have suffered a brain injury, or are currently experiencing drug or alcohol withdrawal
Have a mental disorder such as schizophrenia
Are under an electroconvulsive treatment (ECT)
Doctors don't generally recommend amitriptyline for managing pain in pregnant women due to the availability of other safe medications. If you become pregnant, you may continue taking amitriptyline if you have discussed the risks and advantages with your doctor compared to ceasing therapy or using alternative medicines.
It is especially crucial during the first and third trimesters, when amitriptyline may adversely affect the developing infant.
Doctors have witnessed symptoms resembling amitriptyline's side effects or withdrawal symptoms in newborns whose mothers used amitriptyline during the third trimester. If you are expecting and choose to discontinue taking amitriptyline, your doctor will counsel you.
Don't stop taking amitriptyline immediately because you will experience withdrawal symptoms such as nausea, vomiting, lack of appetite, headache, giddiness, chills, sleeplessness, restlessness, or anxiety. Your doctor will guide you on how to discontinue its therapy to prevent these side effects.
Consult your physician if you want to breastfeed while taking amitriptyline. Amitriptyline is excreted in milk at minute levels that are unlikely to damage a breastfeeding newborn.
If you are taking amitriptyline for depression, breastfeeding is typically safe as long as your infant is healthy, was not delivered prematurely, and is monitored for possible side effects such as sleepiness. However, always see your physician first due to the numerous considerations involved.
Although the FDA has not authorized amitriptyline for migraine prophylaxis (prevention), evidence indicates that it is helpful at low dosages. Medical professionals may prescribe amitriptyline for patients to prevent migraines.
Doctors recommend that you take amitriptyline in the evening or just before bed because it may make you feel tired. Although you may begin to feel better after one or two weeks, it may take up to six weeks for amitriptyline to start working as a painkiller.
Discuss your symptoms with your doctor if you believe amitriptyline may assist you with migraine attacks. Your doctor can assist you in weighing the risks and advantages of amitriptyline therapy.
Amitriptyline | StatPearls