From the Research
Amitriptyline is the first-line prophylactic medication for post-traumatic headache in patients with mild concussion. The typical starting dose is 10-25 mg taken orally at bedtime, which can be gradually increased to 50-100 mg if needed and tolerated 1. Treatment should continue for at least 4-6 weeks before assessing effectiveness, and if beneficial, it should be maintained for 3-6 months before attempting to taper. Amitriptyline works by modulating pain pathways through inhibition of serotonin and norepinephrine reuptake, which helps reduce headache frequency and intensity. It also has the added benefit of improving sleep quality, which is often disrupted following concussion. Common side effects include drowsiness, dry mouth, and constipation, so it's best administered at night. For patients who cannot tolerate amitriptyline, alternatives include nortriptyline (which has fewer side effects) or other preventive medications such as topiramate or propranolol.
Key Considerations
- The pathophysiology of persistent post-traumatic headache is poorly understood, and management strategies rely on medications used for migraine or tension-type headache 2.
- High-quality trials are urgently needed to support clinical decision-making and optimize management strategies for persistent post-traumatic headache 2.
- A multifaceted approach is needed to address all the possible causes of headache and any comorbid conditions that may delay recovery or alter treatment choices 3.
- Non-pharmacological approaches such as adequate hydration, regular sleep patterns, and gradual return to activities should be combined with medication to optimize recovery from post-traumatic headaches.
Treatment Approach
- Start with a low dose of amitriptyline (10-25 mg) and gradually increase as needed and tolerated 1.
- Monitor for common side effects such as drowsiness, dry mouth, and constipation.
- Consider alternative medications such as nortriptyline, topiramate, or propranolol if amitriptyline is not effective or tolerated.
- Emphasize the importance of non-pharmacological approaches such as adequate hydration, regular sleep patterns, and gradual return to activities to optimize recovery.