From the Guidelines
Amitriptyline is a recommended alternative to SSRIs for relieving chronic headaches, particularly for patients who experience migraines on ≥2 days per month despite optimized acute treatment. According to the study published in Nature Reviews Neurology in 2021 1, amitriptyline is listed as a second-line medication for the preventive treatment of migraines. The study suggests using beta blockers, topiramate, or candesartan as first-line medications, but amitriptyline is a viable option for patients who may not respond to these treatments.
Some key points to consider when using amitriptyline for chronic headache relief include:
- Starting with a low dose (10-25mg at bedtime) and gradually increasing as needed to minimize side effects
- Monitoring for potential side effects, such as drowsiness, dry mouth, and constipation
- Considering alternative treatments, such as beta blockers (e.g., propranolol), topiramate, or candesartan, if amitriptyline is not effective or tolerated
- Individualizing treatment based on headache type, medical history, and potential side effects, with regular follow-up to assess effectiveness and adjust as needed.
It's essential to note that the treatment of chronic headaches should be tailored to each patient's specific needs and medical history, and amitriptyline may not be suitable for all patients. However, based on the available evidence, amitriptyline is a recommended alternative to SSRIs for relieving chronic headaches, particularly for patients with migraines 1.
From the FDA Drug Label
Amitriptyline hydrochloride should be used with caution in patients with impaired liver function. The biochemical activity of the drug metabolizing isozyme cytochrome P450 2D6 (debrisoquin hydroxylase) is reduced in a subset of the caucasian population (about 7 to 10% of Caucasians are so called “poor metabolizers”); While all the selective serotonin reuptake inhibitors (SSRIs), e.g., fluoxetine, sertraline, and paroxetine, inhibit P450 2D6, they may vary in the extent of inhibition.
Amitriptyline is an alternative to an SSRI to relieve chronic headaches, as it is a tricyclic antidepressant that can be used for this purpose.
- Key considerations:
- It should be used with caution in patients with impaired liver function.
- The dose may need to be adjusted based on the patient's clinical response, especially in "poor metabolizers" or when co-administered with other drugs that inhibit cytochrome P450 2D6, such as SSRIs 2.
- Patients should be monitored for potential side effects, such as anticholinergic effects, and the dose should be adjusted accordingly 2.
From the Research
Alternatives to SSRIs for Relieving Chronic Headaches
- Tricyclic antidepressants, such as amitriptyline, have been shown to be effective in reducing headache activity and disability in patients with chronic tension-type headaches 3, 4
- Non-pharmacologic treatments, including stress management therapy, relaxation, cognitive-behavioral therapy, and acupuncture, may also be effective in relieving chronic headaches 3, 5, 6
- Other alternatives to SSRIs include:
- Butterbur extract and vitamin B2, which have shown efficacy in preventing chronic headaches 5
- Anticonvulsant drugs, such as sodium valproate, topiramate, or gabapentin, which may be effective in reducing headache frequency and severity 6
- Noradrenergic and specific serotonergic antidepressants, such as mirtazapine, which may be used as an alternative to SSRIs 6
- It's worth noting that the effectiveness of these alternatives may vary depending on the individual patient and the specific type of headache being treated 4, 7