Amitriptyline--preventive treatment of migraine headache symptoms

Elavil, or now commonly called by the generic name, amitriptyline, came out in 1961 and is one of the oldest drugs used for migraine prevention currently.  Although originally intended for treatment of depression by the FDA at doses of 75-150 mg, headache doctors successfully use lower doses such as 10-30 milligrams taken at bedtime.  Psychiatric level treatment of 75-150 mg may have side effects of early morning drowsiness, a dry mouth, constipation, and possible weight gain.  However, using 10-30 mg of amitriptyline at night for headache doesn’t usually cause weight gain and the side effects are more tolerable.  If there is a problem tolerating a limiting side effect, which is usually morning drowsiness, the patient could try starting at one half of 10 mg or 5 mg for a few weeks and then advancing to 10 mg.  Taking the drug earlier in the evening may also be helpful.  That is, if the patient goes sleep at 10:00 they would take amitriptyline at 9 PM.

The drug is useful for migraine patients also because they commonly have psychiatric illness such as depression (50% comorbid with migraine) or generalized anxiety disorder (GAD) (40 % comorbid with migraine) and insomnia and amitriptyline is the only recommended drug for migraine prevention which really helps with sleep.  It is a class 2 drug and is not addictive.  It works on dopamine receptors to help migraine and also puts patients into deep levels of sleep.  Research sleep studies on migraine patients show that they are usually in light sleep (stage 1 or 2 sleep).  However, treated with amitriptyline they may go to deeper stages of sleep such as stage 3 or 4 which is good for headache.

It is a class B drug for migraine prevention according to the American Academy of Neurology.  My personal experience is that it is also a useful drug for nocturnal, middle of the night, and early morning “wake up” headaches.  It also has a a recommendation also for use with tension-type headache at a dose of 75-150 mg.  Migraine patients commonly also may have Tension Type Headache.  Amitriptyline helps with muscle tenderness.

Another good aspect of the drug is that it is very cheap.  In Dallas Walmart sells it for $3-4 and I encourage patients to pay cash for it because their co-pay card price for other migraine preventive drugs may be $5-20.   

Another drug in this class which may also help but does not have as many listed recommendations is Pamelor (nortriptyline) 25-50 mg taking at bedtime.