Amitriptyline

Reduce migraine frequency with Amitriptyline on prescription

Amitriptyline is a tricyclic antidepressant and powerful painkiller that is often prescribed for migraine prevention (prophylactic therapy). 

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Information

Reviewed by Dr Yasmin Aghajan, MD

Information last reviewed 08/01/19

About

What is Amitriptyline?

Amitriptyline (also known as Elavil) is a white, odorless, crystalline compound which is soluble in water. Amitriptyline is used as a preventive medication for migraines. Clinical studies have shown that oral Amitriptyline helps with diabetic neuropathic pain, neurogenic pain syndromes, non-malignant pain (e.g., post-herpetic neuralgia, fibromyalgia).

How does Amitriptyline work for migraine relief?

Amitriptyline is a type of tricyclic antidepressant. That means that it is used primarily to treat depression, but at lower doses, it can be effective for reducing the pain associated with migraine. It works by increasing  levels of serotonin and norephinephrine in the brain. These chemicals can help improve mood, but they also influence how your nerves receive pain signals. In this way, Amitriptyline is able to reduce migraine pain. 

How effective is Amitriptyline for migraine?

In 2011, a study demonstrated that Amitriptyline was effective at reducing the frequency of migraines by approximately 50% after 8 weeks of taking Amitriptyline. 

How long does Amitriptyline take to work?

It can take 4-6 weeks before you experience the full effects of Amitriptyline. Usually, after the first week, you would notice a reduction in migraine pain, but it can take longer. If you do not experience any effects to start with, you should try it for at least 6 weeks to see if it has any effects. 

Ingredients

Active ingredients

Each tablet for oral administration contains 10 mg, 25 mg, 50 mg, 75 mg, 100 mg or 150 mg amitriptyline hydrochloride. The strengths available through Medzino are 10mg and 25mg, if you require something stronger, we recommend that you speak to a doctor face-to-face. The anti-migraine mechanisms are generally speculative and little understood. Amitriptyline works on nerve cells in the brain and spinal cord. Its effectiveness with regard to migraine headaches is unrelated to whether or not the patient suffers from depression.

Inactive ingredients

  • Colloidal silicon dioxide,
  • Hydroxypropyl cellulose,
  • Hydroxypropyl methylcellulose,
  • Lactose, magnesium stearate,
  • Microcrystalline cellulose,
  • Polyethylene glycol,
  • Pregelatinized starch (corn) and titanium dioxide.

Please note that different strengths of tablet may contain different coloring agents. In addition, different brands of generic medication may contain different active ingredients.

Dosage

Amitriptyline dosage

As a preventive agent for adults with migraine attacks, amitriptyline should initially be taken at low doses 10-25 mg daily. It is best taken at night, due to its potential to cause sleepiness. If tolerated, the dosage can be increased in steps of 10-25 mg every 3-7 days in 1-2 divided doses. The usual dose is 25-75 mg. Doses over 100 mg should be used with caution. Doses above 75 mg should be used with caution in the elderly and patients with cardiovascular disease. The maximum strength per dose should be 75 mg.

Note that after taking Amitriptyline for a long duration, patients should not abruptly stop the treatment as it can cause nausea, headache, and malaise. Furthermore, gradual dosage reduction has been reported to produce symptoms such as irritability, restlessness, nightmares and sleep disturbances. Withdrawal symptoms may occur within 5 days of stopping treatment. They are usually mild, but can be severe in some cases. It is advised to reduce the dose gradually over about 4 weeks or longer if these withdrawal symptoms emerge.

Is it possible to overdose on Amitriptyline?

Yes. If an adult ingests 750 mg or more, this can lead to a high level of toxicity. This can be significantly aggravated if you ingest amitriptyline together with alcohol or other psychotropic agents. Symptoms of overdose include low blood pressure, confusion, convulsions, dilated pupils and other eye problems, lack of concentration, drowsiness, hallucinations, impaired heart function, rapid or irregular heartbeat, low body temperature, stupor, unresponsiveness, coma. If you fear that you or someone you know is overdosing, then immediate medical and hospital attention is required.

What should I do in case I miss a dose of Amitriptyline?

If you miss a dose of Amitriptyline, take it as soon as you remember. In case you only remember when it is time for your next dose, stick to your regular dose and do not take it twice to make up for the dose you missed. Try to take your doses at the same time each day in order to avoid forgetting it.

How to take Amitriptyline

Always take Amitriptyline as directed by the prescribing physician. Usually, you would take one tablet once a day at night. You may swallow the tablet with water. Amitriptyline does not need to be taken on an empty stomach. 

What should I do if I have taken too much Amitriptyline?

An overdose of Amitriptyline can be dangerous. You should seek immediate medical advice and call the Poison Control Centre on 1-800-222-1222. Amitriptyline overdose can cause serious symptoms such as:

  • Vomiting
  • Shaking
  • Drowsiness
  • Altered heartbeat
  • Seizures

If you experience any of these symptoms, you should seek immediate medical attention, such as going to the ER.

Side Effects

Amitriptyline side effects

Common side-effects of amitriptyline:

  • Dry mouth
  • Weight gain
  • Constipation
  • Sedation
  • Fatigue
  • Blurred vision
  • Nausea and vomiting
  • Weakness
  • Changes in sex drive or ability
  • Confusion
  • Excessive sweating
  • Headaches
  • Unsteadiness
  • Difficulty urinating
  • Pain in hands and/or feet

If any of these side-effects persist or manifest themselves in a severe way, consult your primary care physician or prescriber.

Potential serious side-effects include:

  • Increase or emergence of depression and/or suicidal thoughts and behavior:
    • Amitriptyline is, first and foremost, an antidepressant. There are some studies suggesting that anti-depressants may have worsening effects on depression and suicidality. Patients using antidepressants should be monitored closely for worsening symptoms such as suicidal ideation and unusual changes in behavior, especially during the first months of usage. Call a healthcare provider right away if you or someone you know experiences any of the following symptoms, especially if they are new or have worsened: suicidal thoughts, suicide attempts, depression, anxiety, agitation, restlessness, panic attacks, insomnia, irritability, aggressive behavior, dangerous impulses, mania, other unusual behavior, eye pain, changes in vision, swelling or redness around the eye.
  • Cardiac dysrhythmias such as tachycardia (when your heart rate exceeds the normal resting rate. Usually, a resting rate over 100 beats per minute is considered tachycardia)
  • Changes in atrioventricular (AV) conduction (Pertaining to the atria, the upper chambers of the heart and the ventricles, the lower chambers of the heart)
  • Heart block (a condition where the heart beats more slowly or with an abnormal rhythm)
  • Hallucinations (when a person experiences something that does not exist outside of their mind, for example, seeing, hearing, smelling, tasting or feeling things that are not actually there)
  • Slow or difficult speech
  • Crushing or heavy chest pain
  • Severe skin rash
  • Swelling of the tongue and face
  • Yellow skin or eyes (jaundice)
  • Jaw, neck, and back muscle spasms
  • Unusual bleeding
  • Uncontrollable shaking of a body part
  • Seizures

If you experience any of these severe side-effects, contact your doctor immediately or go to an emergency room right away.

Contraindications

  • Patients who have shown prior hypersensitivity to Amitriptyline.
  • Patients who take monoamine oxidase inhibitors. Hyperpyretic crises, severe convulsions and deaths have occurred in patients who have ingested monoamine oxidase inhibitors and amitriptyline at the same time. If the patient wants to replace monoamine oxidase inhibitors with amitriptyline hydrochloride, the 14 days should be allowed to elapse before replacing medication. Amitriptyline hydrochloride should then be used cautiously and with gradual increase in dosage until achieving an optimal response.
  • Patients recovering from myocardial infarction.
  • Patients during the manic phase of bipolar disorder.

Patients should consult their physicians and use amitriptyline with caution if they have a history of cardiovascular disease, chronic constipation, diabetes, epilepsy, bipolar disorder, psychosis, hyperthyroidism, increased intra-ocular pressure, suicidal behavior, pheochromocytoma, prostatic hypertrophy, susceptibility to angle-closure, glaucoma, urinary retention.

Drug interactions

Some drugs may interfere with the effects of Amitriptyline. Do not take Amitriptyline at the same time as the following drugs: Arbutamins, Disulfiram, thyroid supplements, NSAIDs (such as Ibuprofen), blood thinners (such as Warfarine), anticholinergic drugs (such as Benztropin, Balladonna, Alkaloids), certain drugs for high blood pressure (such as Clonidine, Guanabenz, and Resperine), Monoamine Oxidase Inhibitors (such as Isocarboxazid, linezolid, Methylene Blue, Moclobemide, Phenelzine, Procarbazine, Rasagiline, Safinamide, Selegiline, Tranylcypromine), Cimetidine, Terbinafine, drugs to treat irregular heart rate (such as Quinidine, Propafenone, Flecainide), antidepressants (such as SSRIs including Paroxetine, Fluoxetine, Fluvoxamine), antihistamines (such as Cetirizine, Diphenhydramine), drugs for sleep or anxiety (such as Alprazolam, Diazepam, Zolpidem), muscle relaxants, and narcotic pain relievers (such as Codeine). Always inform your doctor of the medications you are taking before using this Amitriptyline.

Can I use Amitriptyline when pregnant or breastfeeding?

There is little data on whether pregnant women can use Amitriptyline, but it has been shown to cross the placenta, although the effects of this have not been adequately studied. Generally, it is not recommended unless absolutely necessary. In this case, very careful consideration is necessary of both risks and benefits. Do not self-medicate if you are pregnant but talk to your health physician. Regarding breastfeeding, risks to the baby must be considered as Amitriptyline and its metabolites are emitted into breast milk. Due to the benefits of the breast milk for the child in contrast to the benefits of the therapy for the mother, a decision on whether to continue or abort the therapy should be carefully taken with the help of a physician.

Does Amitriptyline affect fertility?

Some clinical studies on animals have shown reproductive toxicity. However, there are no data on the repercussions of Amitriptyline for human fertility.

Q&A

Disclaimer: This is not medical advice. You and your physician will determine if and how you should take any medication prescribed to you following a medical consultation.

  1. Drugbank, ‘Amitriptyline’ https://www.drugbank.ca/drugs/DB00321 [accessed 9 March 2019]
  2. Garza, Ivan, Swanson, Jerry W, ‘Prophylaxis of migraine’, in Neuropsychatr Dis Treat, 2:3 (2006), pp. 281-291, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2671824/ [accessed 9 March 2019]
  3. Reddy, Doodipala Samba, ‘Migraine Prohylaxis (Preventive Antimigraine Therapy)’, in Expert Rev Clin Pharmacol, 6 (2013), pp. 271-288 https://www.medscape.com/viewarticle/804034_14 [accessed 9 March 2019]
  4. National Headach Foundation, ‘Amitriptyline - Elavil’ https://headaches.org/2007/10/25/amitriptyline-elavil/ [accessed 9 March 2019]
  5. National Institute for Health and Care Excellence, ‘Amitriptyline Hydrocholoride’ https://bnf.nice.org.uk/drug/amitriptyline-hydrochloride.html#indicationsAndDoses [accessed 9 March 2019]
  6. NHS, ‘Amitriptyline for pain and migraine’ https://www.nhs.uk/medicines/amitriptyline-for-pain/ [accessed 9 March 2019]
  7. PubChem, ‘Amitriptyline’ https://pubchem.ncbi.nlm.nih.gov/compound/amitriptyline#section=Top [accessed 9 March 2019]
  8. Couch JR, 'Amitriptyline in the prophylactic treatment of migraine and chronic daily headache'., in Headache, 51, (2011), pp.33-51 https://doi.org/10.1111/j.1526-4610.2010.01800.x

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