From the Guidelines
Amitriptyline is a recommended medication for the management of chronic headaches, particularly for patients with mixed migraine and tension-type headache, due to its superior efficacy compared to other treatments 1. The role of amitriptyline in headache management is well-established, with studies showing its effectiveness in reducing the frequency and severity of headaches.
- The dosages that were most efficacious in clinical trials ranged from 30 to 150 mg/d, with most patients responding to 25-50 mg daily.
- Common side effects include drowsiness, weight gain, and anticholinergic symptoms, which can be managed by taking the medication at bedtime.
- Amitriptyline works by increasing levels of serotonin and norepinephrine in the brain, which helps regulate pain pathways and improve sleep quality.
- The medication should be taken consistently for at least 6-8 weeks before determining its effectiveness, as the full preventive benefits may take time to develop.
- It is essential to taper the medication slowly when discontinuing to avoid withdrawal symptoms.
- Patients should be aware that amitriptyline is not intended for acute headache relief but rather to reduce the frequency and severity of headaches over time, as supported by the study published in the Annals of Internal Medicine 1.
From the Research
Role of Amitriptyline in Managing Chronic Headaches
- Amitriptyline is a tricyclic antidepressant that is considered a treatment of choice for different types of chronic pain, including chronic myofascial pain 2.
- The medication's antinociceptive property is independent of its antidepressant effect, and its analgesic mechanism is believed to involve serotonin reuptake inhibition in the central nervous system 2.
- Amitriptyline is widely used in the prevention of chronic tension-type headache, and studies have shown it to be effective in reducing headache frequency and severity 2, 3.
Efficacy of Amitriptyline in Chronic Headache Management
- A retrospective cohort study found that approximately 3/4 of patients experienced improvement in headache symptoms, and 85% were still taking amitriptyline at the last follow-up appointment 4.
- The study also found that low doses of amitriptyline (≤10 mg daily) were effective and well-tolerated, and may improve medication persistence 4.
- A placebo-controlled trial found that amitriptyline was superior to placebo in reducing headache frequency at 8 weeks, but the difference was not significant at subsequent time points 5.
- However, in a subgroup of patients with chronic daily headache, amitriptyline was statistically significantly superior to placebo at 8 weeks and 16 weeks 5.
Treatment Considerations
- Amitriptyline is one of several prophylactic treatments for chronic daily headache, and can be used in conjunction with nonpharmacologic therapies such as relaxation techniques and cognitive behavior therapy 6.
- The medication should be used with caution, as it can have side effects such as daytime fatigue, and patients should be monitored for medication overuse 4, 6.
- The optimal dose of amitriptyline for chronic headache management is not established, but low doses (≤25 mg daily) may be effective and well-tolerated 4.