Insomnia is a difficult problem which may be chronic for many people, causing them to lose energy and feel out of sorts.  Certain neurological conditions are associated with insomnia and these include migraine, tension type headache, depression, and generalized anxiety disorder. 

This is an article by Britt Talley Daniel MD, retired member of the American Academy of Neurology, migraine textbook author, podcaster, YouTube video producer, and blogger.

Amitriptyline is commonly used, either short-term or chronically, for insomnia.  Although there may be side effects, most persons can live with them.  In general, the beneficial effects outweigh possible side effects.

Since migraine, depression, and pain are commonly found with insomnia, amitriptyline may help with all of these other problems as well making it possible for the doctor to treat other comorbid conditions of insomnia with a single pill.

Also, amitriptyline comes with a large range of different dose sizes, allowing adequate titration for different persons.  It is a very cheap medication and often times it is cheaper to pay the pharmacist than to use your insurance policy. 

Although a medium level drug for insomnia, amitriptyline works for many persons. 

Although amitriptyline has been around for a long time, it is still a popular, low-cost generic medication that is commonly used in medicine.

It is not addictive and not a benzodiazepine drug like Ambien (zolpidem) which is a class 4 narcotic and requires monitoring.

Read my Mini Book on Migraine Here.

In general, how does amitriptyline work?

Amitriptyline is called a tricyclic antidepressant (TCA).  Tricyclic means that there are 3 benzene rings in the chemical make-up of the drug.  Amitriptyline increases neurotransmitters in the brain such as serotonin and norepinephrine which help modulate sleep, pain, and anxiety. 

How does amitriptyline work to produce sleep?

It is not fully understood how amitriptyline helps sleep other than it does block histamine, which produces drowsiness.  Doctors prescribe amitriptyline as a sleep aid, which is an off-label use of the drug which originally was released by the FDA for treating depression.

Off-label use means prescribing a drug for a medical problem that is different than the one originally intended by the FDA.

What are common side effects of amitriptyline?

Common side effects of amitriptyline include:

Weight gain.

Constipation

Dry mouth, rarely leading to tooth loss

Early morning drowsiness

Headache

Trouble urinating

Orthostatic blood pressure drop-means drops following standing up from sitting

Blurred vision

The most frequent side effects are weight gain, constipation, early morning drowsiness, and dry mouth.

What is the typical dosage prescribed for sleep?

The dose of amitriptyline starts at 10 mg and goes up to 150 mg.  I like to start with the 10 mg dose for sleep which is an extremely small sized pill that is very easy to swallow.  On recheck in the clinic that dose could be advanced to 30 or 50 mg, at which most persons will sleep well.

In general, children and adolescents (ages 9-13) need lower doses of the medication than older persons.

What are the medical indications for amitriptyline listed by the FDA?

Indications for the drugs are depression, which was the original indication for prescribing it, neuropathic pain, such as diabetic polyneuropathy, postherpetic neuralgia, migraine headache, and fibromyalgia.

How is amitriptyline used for depression?

The dose for treating depression in adults is generally 75-150 mg, starting at the lower dose of 75 mg and then building up.

What are the effective differences in treating depression using an old drug like amitriptyline, which came out in 1961, versus the SSRI group which started with Prozac in 1990?

Both groups of drugs work effectively well for treatment of depression and no one has ever shown that the SSRIs are better than amitriptyline.  The main difference is that there are usually fewer side effects taking SSRIs versus using amitriptyline.

Amitriptyline has a Black Box Warning regarding increased suicidality risk in children, adolescents, and young adults with major depressive or psychiatric disorders.

How is amitriptyline used for treatment of migraine?

For treatment of migraine alone and no other comorbid condition, a starting dose of 10-30 mg would be helpful for migraine prevention.

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

When you say that amitriptyline is cheap, what do you mean?

Some drug plans provide amitriptyline free or for a charge of 2-3 dollars for a month’s prescription.

Can amitriptyline be used during pregnancy and breastfeeding?

Caution is advised regarding the use of amitriptyline during the 3rd trimester of pregnancy due to risk of teratogenicity.  It may be used during breast-feeding.

Are there certain illnesses that have risk from using amitriptyline?

Caution is advised for:

Heart disease, liver, or kidney problems

Glaucoma-amitriptyline can increase the ocular pressure

Diabetes-causes increased blood sugar

Epilepsy- increased risk of seizures

Bipolar disorder, mania, or schizophrenia

What are the drugs that can interact with amitriptyline?

Monoamine oxidase inhibitors (MAOIs) like selegiline (Eldepryl)-seizures or death

Quinidine- heart rhythm problems

Opioid narcotics-can increase drowsiness and raise the risk for serotonin syndrome, which can cause increased blood pressure and elevated heart rate

Epinephrine and norepinephrine-can increase blood pressure, headaches, and chest pain

Topiramate-can raise level of amitriptyline producing side effects

In closing.

Amitriptyline is a cheap, non-addictive drug that is commonly used for insomnia.

Read my Big Book on Migraine Here.

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All the best.

Britt Talley Daniel MD