Amitriptyline Dosing for Headache Prevention
For headache prevention, amitriptyline should be started at 10-25 mg daily at bedtime and gradually titrated to an effective dose of 30-150 mg daily, with most patients responding to lower doses of 10-25 mg daily. 1, 2
Dosing Recommendations
Initial Dosing
- Start with 10-25 mg once daily at bedtime 1, 3
- For elderly or sensitive patients, consider starting at a lower dose of 10 mg 1
- Bedtime administration helps minimize daytime sedation 1
Titration
- Increase by 10-25 mg every 2-3 weeks as tolerated 1
- Slow titration improves tolerability and adherence 2
- Assess response after 4-6 weeks at a stable dose 1
Effective Dosing Range
- Most patients with headache respond to 10-25 mg daily (lower than doses used for depression) 2
- Maximum recommended dose is 150 mg daily for headache prevention 1
- Clinical evidence shows effectiveness at lower doses than traditionally used in clinical trials 2
Effectiveness by Headache Type
- Migraine: Effective for prevention at doses of 30-150 mg daily 1
- Chronic tension-type headache: Effective at doses of 25 mg daily 4
- Episodic tension-type headache: Less effective than for chronic tension headaches 4
- Chronic daily headache: Shows significant benefit over placebo at 8 and 16 weeks 5
Monitoring and Side Effects
Common Side Effects
- Daytime fatigue (most common, reported in 11% of patients) 2
- Anticholinergic effects: dry mouth, blurred vision, constipation 1
- Sedation (can be beneficial for patients with sleep disturbances) 1
- Weight gain 1
Monitoring
- Assess therapeutic response after 6-8 weeks 1
- Monitor for side effects at each visit
- Consider ECG monitoring in patients with cardiac risk factors due to potential QTc prolongation 1
Clinical Pearls
- Low doses (10-25 mg) are often effective for headache prevention, unlike the higher doses needed for depression 2
- Lower doses are associated with better adherence and fewer side effects 2
- Therapeutic effect may take 4-6 weeks to develop 3
- Amitriptyline can be continued for maintenance therapy at the lowest effective dose 3
- Pediatric dosing (for children >12 years): 1 mg/kg daily has shown effectiveness with minimal side effects 6
Treatment Duration
- Continue effective treatment for at least 3-6 months 3
- After achieving stable improvement, consider gradual dose reduction to the lowest effective maintenance dose 3
- Long-term therapy may be needed for patients with chronic headache disorders 1
Amitriptyline remains one of the most evidence-supported preventive medications for migraine and chronic headache disorders, with effectiveness demonstrated even at doses lower than those traditionally used in clinical trials 1, 2.