Amitriptyline (Elavil) and other drugs in the family of tricyclic antidepressants have been proven to be very effective in the preventive treatment of migraine headaches and many other painful conditions.
Several double-blind, placebo-controlled trials have proven the utility of amitriptyline for the prevention of migraines. Amitriptyline is also an effective antidepressant, so it is perfect for patients with anxiety or depression. However, its effect on migraines and pain is proven to be independent of its effect on depression. That is, even in the absence of depression or anxiety, the drug prevents migraines and relieves pain.
Amitriptyline has an additional benefit for people with insomnia – it helps sleep. On the other hand, in some people this effect lasts too long and they feel sleepy or tired the next day. In such cases we try a different and less sedating tricyclic antidepressant, such as nortriptyline (Pamelor), desipramine (Norpramine), or protriptyline (Vivactil). This potential side effect is why we always start this and most other preventive drugs at a small dose, 10 or 25 mg nightly. Some people need only 25 mg, while other require 100 mg. This is often due to the variable absorption of the drugs. Fortunately, in case of amitriptyline a simple blood test can tell us how much of the drug is being absorbed. Some patients will achieve a good therapeutic level with 25 mg, while others need 100 or 150 mg. So, in the absence of side effects and lack of relief, the dose is slowly increased. When we get to 75 or 100 mg, blood test can provide guidance about the safety of further escalation of the dose.
High levels of tricyclic antidepressants can be dangerous, leading to arrhythmias – irregular heart rhythms. We usually obtain an electrocardiogram in the elderly and those at risk for heart disease before starting amitriptyline. Two other more common side effects of amitriptyline are constipation and dry mouth. In many patients constipation can be successfully managed with over-the-counter remedies, such as Senokot S or Miralax.
