Can patients with headaches take amitriptyline (as needed, prn)?

From the Guidelines

Amitriptyline is not recommended for as-needed (PRN) use in treating headaches, as it works best when taken daily as a preventive medication. The most recent and highest quality study, published in 2020 in JAMA Neurology 1, supports the use of amitriptyline as a preventive treatment for migraine headaches, but not for acute treatment. According to this study, amitriptyline is effective in reducing headache frequency and severity when taken daily, typically at doses of 10-150 mg once daily at bedtime.

Key Points to Consider

• The medication needs to build up in the system over several weeks to effectively reduce headache frequency and severity, which is why consistent daily dosing is essential.
• Taking amitriptyline only when headaches occur won't provide benefit and may increase side effects like drowsiness, dry mouth, and dizziness without the therapeutic advantage.
• For acute headache treatment, medications specifically designed for immediate relief such as NSAIDs, triptans, or other prescribed acute treatments are more appropriate.
• If experiencing frequent headaches requiring medication, it's best to consult a healthcare provider about establishing both a preventive regimen and an appropriate as-needed treatment plan.

Recommendations for Treatment

• Use ibuprofen to treat pain in children/adolescents; in adolescents consider sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral 1.
• Consider preventive treatments in children/adolescents with frequent or disabling headaches or medication overuse 1.
• Discuss with patients/families whether to use a preventive medication, since placebo was as effective as the studied medication in many trials 1.

From the FDA Drug Label

Dosage should be initiated at a low level and increased gradually, noting carefully the clinical response and any evidence of intolerance. The usual maintenance dosage of amitriptyline HCl is 50 to 100 mg per day.

The FDA drug label does not provide information on taking amitriptyline as needed (prn) for headaches. The label discusses dosage initiation, increases, and maintenance, but does not mention prn use for this specific condition 2.

From the Research

Amitriptyline for Headache Treatment

• Amitriptyline is a tricyclic antidepressant that has been used to treat chronic headache disorders, including migraines and neuropathic pain 3, 4, 5.
• The evidence suggests that amitriptyline can be effective in reducing headache frequency and severity, with some studies showing improvement in up to 75% of patients 3, 5.
• The typical dosage of amitriptyline for headache treatment is lower than that used for depression, ranging from 10-25 mg daily 3, 4.
• Common side effects of amitriptyline include daytime fatigue, dry mouth, and sedation, but these can be minimized with low starting doses and careful dosage titration 3, 4.

Use of Amitriptyline as Needed (PRN)

• There is limited evidence specifically addressing the use of amitriptyline as needed (PRN) for headache treatment 6.
• One study found that patients with headache after traumatic brain injury who took amitriptyline PRN did not show significant improvement in headache frequency or severity, but this may have been due to poor compliance and study limitations 6.
• Another study suggested that amitriptyline may be effective in preventing migraines, but the evidence for PRN use is not well established 5.

Clinical Considerations

• Amitriptyline should be used judiciously, taking into account the patient's medical history, comorbidities, and potential side effects 4, 5.
• Patients should be counseled about the possibility of withdrawal effects and the importance of adherence to the prescribed dosage regimen 5.
• Further research is needed to determine the efficacy and safety of amitriptyline for headache treatment, particularly in specific patient populations and for PRN use 6, 7.