Amitriptyline is an old-style anti-depressant that we sometimes use for pain conditions at lower doses than depression. As amitriptyline works on the nervous system, it’s more effective for neuropathic pain rather than the pain caused by musculoskeletal disorders. So how do we use amitriptyline for pain?

Amitriptyline for pain: how does it work? 

Generally, amitriptyline works by increasing hormones such as serotonin and norepinephrine. These hormones play a role in pain modulation. Therefore, we suspect this medication accumulates outside the nerve cells and reduces pain messages in the spinal cord.

Overall, it helps conditions associated with central sensitisation, i.e., the exaggerated response of the pain alarm system to peripheral stimulation.

Which conditions respond to amitriptyline? 

low back pain

Overall, we use amitriptyline ‘off-label’ for many pain conditions such as:

  • Nerve inflammation due to conditions such as diabetes
  • Pinched nerve pain, also known as ‘Sciatica’ from the lumbar spine
  • Chronic musculoskeletal conditions such as arthritis or chronic shoulder or low back pain. Amitriptyline is particularly effective for chronic pain states where the pain system is hypersensitised. However, recent evidence suggests less evidence for effectiveness in chronic musculoskeletal pain compared to conditions such as depression.

Amitriptyline dose for pain

amitriptyline

The correct dose of amitriptyline for pain conditions is still unknown. However, we know that the dose is much lower than used for depression.

When starting amitriptyline, it is important to titrate the dose, meaning that you start low and slowly increase as tolerated. Generally, titrating the dose will reduce side effects. Overall, the dose ranges from 10 to 75mg daily. The maximal dose of amitriptyline for pain is about 75mg daily. Anything above 75mg is probably not effective for pain.

Amitriptyline is long-acting, so it only needs to be taken once daily. However, it is best to take it a couple of hours before bedtime.

Amitriptyline for pain: adverse effects

Generally, side effects are common when taking amitriptyline for pain. However, as the dose is lower than used for depression, side effects are milder and better tolerated. Often, side effects are temporary and settle after a few weeks, but you may still suffer from adverse effects even after months of using it. Usually, side effects are dose-related and improve with a lowering of dose.

Common side effects include sleepiness or drowsiness, headache, increased appetite, and dry mouth. Generally, using amitriptyline at night will reduce tiredness the next day.

Less common side effects include skin rash, mood change, anxiety, and increased bleeding.

However, amitriptyline at lower doses for chronic pain has few side effects.

Precautions and contraindications

In general, amitriptyline should not be used if you’ve had a heart attack, a heart rhythm disorder, or recent seizures or strokes.

As amitriptyline can make you excessively tired, you should avoid driving or operating dangerous equipment if feeling tired.

Finally, you should be careful with alcohol as the effects of alcohol can be magnified while on this drug. Also, you should let your doctor know if you are taking other medications such as thyroxine, other anti-depressants, and certain analgesics such as tramadol.

Frequently asked questions about amitriptyline for pain

How should I increase the dose of amitriptyline?

Generally, you should start at a low dose (10-25mg) and increase by 10mg every 7-10 days.

How long does amitriptyline take to work for pain? 

Unlike regular pain medication, amitriptyline does not work immediately.  Usually, you will notice an effect after a few weeks. Increasing the dose by 10-25mg may increase the effects.

Is amitriptyline addictive?

No. However, it is vital that when you want to stop amitriptyline, you should do so slowly over about a month. Generally, we suggest reducing the dose by 1/2 for two weeks, then a 1/4 for another two weeks.

Amitriptyline and sleep: is it a sleeping tablet?

Amitriptyline can cause drowsiness and can be taken to help sleep. By allowing rest, pain can be improved. But it is not thought to be a sleeping tablet.

How long do I need to take amitriptyline?

There are no definite rules on how long you should take amitriptyline for pain. However, we generally say you should take this medication for at least 3-6 months.

Can I take ibuprofen with amitriptyline? 

Yes. Ibuprofen or other NSAIDS work to reduce inflammation and improve pain in many musculoskeletal problems. Generally, it is safe to take these two tablets together.

Are there interactions between amitriptyline and alcohol? 

Yes. Amitriptyline will increase the sedative effects of alcohol. In general, we suggest you moderate your intake of alcohol while on amitriptyline.

Alternative to amitriptyline for pain

box of pregabalin

Generally, if patients cannot tolerate amitriptyline for pain, we consider other medications. Sometimes, people take alternative drugs.

Nortriptyline

This drug is a tricyclic antidepressant, which is in a similar class to amitriptyline. Although it has similar side effects, some people experience fewer side effects than amitriptyline.

Duloxetine

This drug is a different antidepressant that works on other brain and spinal cord receptors. It works to increase the levels of serotonin and norepinephrine in the brain. Although its primary use is in depression, recent evidence suggests that this drug is also effective for pain in musculoskeletal disorders such as chronic arthritis or nerve pain such as sciatica.

Pregabalin or Gabapentin

We know these drugs by the common brand name of Neurontin or Lyrica. It is an anti-convulsant drug to prevent seizures. However, recent studies suggest it is effective for pain. Nevertheless, it is a drug with significant side effects such as drowsiness. As such, we use Lyrica less frequently for pain.

Which is better for pain gabapentin or amitriptyline? 

Overall, amitriptyline has the upper hand in the treatment of pain. It is less addictive, has fewer side effects, and is generally more effective than gabapentin.

Can I take amitriptyline and gabapentin together? 

Yes, but you need to be careful of side effects such as drowsiness. We recommend you speak to a pain consultant if you need both tablets together.

Final word from Sportdoctorlondon about amitriptyline for pain 

We think Amitriptyline is the medication of choice for assisting in treating chronic pain such as nerve trapping or chronic shoulder or back pain. However, it is vital to make sure you take the medication correctly. Also, you should be aware of potential side effects.

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