Amitriptyline For Migraine. 2023

Elavil, or now commonly called by the generic name, amitriptyline, came out in 1961 and is one of the oldest drugs used for migraine prevention currently. Although originally intended for treatment of depression by the FDA at doses of 75-150 mg, headache doctors successfully use lower doses such as 10-30 milligrams taken at bedtime to help migraine and insomnia.

Be sure you have migraine read my article, “What is Migraine?” on my website, www.doctormigraine.com.
The question arises as to why, or if, an antidepressant like amitriptyline can help migraine? People can have migraine without being depressed and amitriptyline can help persons with Migraine who are not depressed.

Sorry, I'm a headache doctor. My experience is that most persons with migraine don't know how to treat it well. One of the answers to effective treatment is to use a triptan early, but, wait, hey, I've got a whole article on "How to Treat Migraine" on my website, doctormigraine.com. Please read this article, click here.

Read my Mini Book on Migraine Here

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.

Amitriptyline is an old tried and true drug for migraine prevention, pain, and insomnia. Small doses are used for migraine to avoid side effects. Amitriptyline is approved by the FDA for treating depression at higher doses. It is approved by the American Academy of Neurology for pharmacologic treatment for migraine prevention.

Related issues.

How does amitriptyline work?

Amitriptyline is termed a tricyclic antidepressant and it works by increasing brain serotonin, which improves mood and improves pain by changing the way nerves receive pain signals.

How to dose amitriptyline.

Psychiatric level treatment of 75-150 mg for depression may have side effects of early morning drowsiness, a dry mouth, constipation, and possible weight gain.

However, using 10-30 mg of amitriptyline at night for headache doesn’t usually cause weight gain and the side effects are more tolerable.

Early morning drowsiness may be a limiting side effect.  If this occurs, the patient should try starting at one half of 10 mg or 5 mg for a few weeks and then advancing to 10 mg.

Taking the drug earlier in the evening may also be helpful.  That is, if the patient goes sleep at 10 PM they would take amitriptyline at 9 PM.

All patients should be instructed that it may take a solid month for amitriptyline to work.

Amitriptyline treatment success used alone

Amitriptyline alone, usually given at night, reduces migraine by about 30%.

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Amitriptyline helps with sleep.

The drug is useful for migraine patients also because they commonly have psychiatric illness such as depression (50% comorbid with migraine) or generalized anxiety disorder (GAD) and panic disorder both of which are 40 % comorbid with migraine. 

Depression and GAD have the common cardinal symptom of insomnia and amitriptyline is the only recommended drug for migraine prevention which really helps with sleep.

Read my article, “Amitriptyline for Sleep,” on my website, www.doctormigraine.com.

Amitriptyline is not addictive.

Amitriptyline is a class 2 drug and is not addictive.  Class 4 drugs are narcotics like the opioid narcotic hydrocodone which is addictive. 

Amitriptyline works on dopamine receptors to help migraine and also puts patients into deep levels of sleep.  Sleep is good for migraine and many migraine patients don’t sleep well.

Research sleep studies on migraine patients show that they are usually in light sleep (stage 1 or 2 sleep).  However, treated with amitriptyline migraine patients may go into deeper stages of sleep such as stage 3 or 4 which is good for headache.

Sleep has 4 stages, stage 1 being light sleep and stage 4 being deep sleep.

Amitriptyline helps nighttime migraine.

My personal medical experience is that amitriptyline is also a useful drug for nocturnal, middle of the night, and early morning “wake up” headaches.

Early morning wake up headaches are a very common problem with many migraine patients.  I encourage them to keep their acute therapy migraine drug, probably a triptan at bedside with a glass of water so they can just roll over, take their medicine, and go back to sleep.

A dreadful mistake for many migraine patients is to not treat at the onset of their migraine and then have to suffer a disabling migraine all that day or longer.

Amitriptyline treats tension-type headache also.

Amitriptyline has a recommendation for use with tension-type headache at a dose of 75-150 mg.  Migraine patients may also have Tension Type Headache which commonly has a physical finding of muscle tenderness of the head when examined by the doctor.  Amitriptyline helps with muscle tenderness.

Read my article, “Migraine or Tension-Type Headache” on my website, www.doctormigraine.com.

Amitriptyline is a very inexpensive drug.

Another good aspect of the drug is that it is very cheap.  In Dallas Walmart sells it for $3-4 and I encourage patients to pay cash for it because their co-pay card price for other migraine preventive drugs may be $5-20.  Sometimes it is free with certain insurances.

Aimovig, one of the new CGRP drugs for migraine, costs $540 per month without insurance.

Amitriptyline is a very small pill.

I’ve had patients, particularly adolescents, who couldn’t take certain pills and referred to them as “that horse pill.” 10 mg amitriptyline is a very tiny, easy to swallow pill.

Amitriptyline and pregnancy and breastfeeding.

Most doctors stop Amitriptyline for patients who plan to get pregnant or breastfeed. Amitriptyline has a small risk for pregnancy and is generally not recommended in pregnancy or while breastfeeding.

A doctor may use it during pregnancy or breastfeeding only if the benefits of taking the medicine outweigh the risks.

Amitriptyline has been linked with a small risk of problems for the unborn baby if you take it in early or late pregnancy.

Amitriptyline and side effects.

Possible side effects are:

constipation

dizziness

dry mouth

sleepiness

difficulty urinating

New patients present with articles they've downloaded from Google listing side effects of Amitriptyline, usually at the psychiatric, anti-depressive dose of 100 mg. They make a 100 mg tab of amitriptyline, but I never use it.

I start with the little tiny 10 mg tab which usually is tolerated pretty well. So, don't other migraine preventive drugs have side effects too-yeah. Read “Side Effects of Preventive Migraine Treatment Drugs” from my website, doctormigraine.com by clicking here.

Consider staying on amitriptyline when you start one of the new CGRP drugs.

Headache doctors started using Aimovig, the first CGRP drug for migraine, in July 2018.

I personally used a lot of amitriptyline before that time, often with other preventive migraine drugs like Depakote, propranolol, or topiramate, but I have always advised patients to stay on their previous preventive drugs when they start one of the new CGRP drugs.  CGRP drugs don’t help sleeping.

Then, many patients will stay on amitriptyline and their CGRP drug to continue sleeping well.

Check out my Big Book on Migraine Here.

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All the best.

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Britt Talley Daniel MD