100 Migraine drugs, A to Z: Amitriptyline
Amitriptyline (Elavil) and other drugs in the family of tricyclic antidepressants have been proven to be very effective in the preventive treatment of migraine headaches and many other painful conditions.
Several double-blind, placebo-controlled trials have proven the utility of amitriptyline for the prevention of migraines. Amitriptyline is also an effective antidepressant, so it is perfect for patients with anxiety or depression. However, its effect on migraines and pain is proven to be independent of its effect on depression. That is, even in the absence of depression or anxiety, the drug prevents migraines and relieves pain.
Amitriptyline has an additional benefit for people with insomnia – it helps sleep. On the other hand, in some people this effect lasts too long and they feel sleepy or tired the next day. In such cases we try a different and less sedating tricyclic antidepressant, such as nortriptyline (Pamelor), desipramine (Norpramine), or protriptyline (Vivactil). This potential side effect is why we always start this and most other preventive drugs at a small dose, 10 or 25 mg nightly. Some people need only 25 mg, while other require 100 mg. This is often due to the variable absorption of the drugs. Fortunately, in case of amitriptyline a simple blood test can tell us how much of the drug is being absorbed. Some patients will achieve a good therapeutic level with 25 mg, while others need 100 or 150 mg. So, in the absence of side effects and lack of relief, the dose is slowly increased. When we get to 75 or 100 mg, blood test can provide guidance about the safety of further escalation of the dose.
High levels of tricyclic antidepressants can be dangerous, leading to arrhythmias – irregular heart rhythms. We usually obtain an electrocardiogram in the elderly and those at risk for heart disease before starting amitriptyline. Two other more common side effects of amitriptyline are constipation and dry mouth. In many patients constipation can be successfully managed with over-the-counter remedies, such as Senokot S or Miralax.
Yes, almost any drug, including those use to treat headaches, can cause or worsen them. And it is also not unusual for one generic to be better than another. The difference is often due to a difference in the inactive ingredients, such as the glue that holds the pill together or the ingredients in the capsule, coloring, etc. All these can cause poor absorption of the active ingredient or cause a headache.
I often see this with triptans – sumatriptan (Imitrex), rizatriptan (Maxalt) and other. I recommend sticking with the generic copy that seems to work better. In the US the pharmacy label has to include the name of the manufacturer, which makes it easier to do that. Otherwise, a change in color, size or shape of the pill will tell you that this is a product from a different manufacturer.
I have taken 20 my amitriptyline for a while and thought it decreased my migraine. Today I started to wonder if it’s possible that it in stead gives me another kind of headache on the top of my head.
I have had a stubborn headache in between my migraines. Since I found your blog I immediately stopped taking any form of caffeine and the ”between headache” almost disappeared. I thought that was just because of the caffeine, but it so happen I got a new kind of amitriptyline, a generic copy, about the same time.
Yesterday I thought about how strange it was that I had woke up from migraine during the night for many days in a row and it led me to suspect that this generic copy of amitriptyline might not contain the same amount of substances that my normal brand, Saroten, does. I decided to take a Saroten 25 mg yesterday evening.
What happened was that I slept longer than the nights before and when I got up I felt more tired and had some kind of headache on the top of my head. I took aspirin to get rid of it, but it was difficult to ease the pain. It led me to take the first aspirin with caffeine for maybe two weeks and it helped a bit.
I recognize this kind of headache from before I withdraw caffeine. I thought I got it as rebound headache from caffeine, but now I started to wonder if I got it from Saroten/amitriptyline.
If so, it would be terrible. It would mean that I get another kind of headache from the medicine I take to prevent migraine. And it’s a kind of headache that make me sleepy, so that I would take more caffeine to reduce it. Which means I would get more migraine!
My plan now is to withdraw amitriptyline and see what happens. Then maybe introduce it again and see if it gives me headache.
Yes, amitriptyline tends to be most sedating, followed by nortriptyline, then, desipramine, and protriptyline is often the least sedating .
Thank you for the great information. Do you know if protriptyline and desipramine are better than Nortriptyline in terms of drowsiness and other side effects? I mostly struggle with brain fog during the day and it’s hard for me to tell if it’s the Nortriptyline or the migraines themselves. I appreciate greatly all the info in your blog. Thank you.