Amitriptyline is an old-style antidepressant that we sometimes use for pain conditions at lower doses than for depression. Because it works on the nervous system, it’s more effective for neuropathic pain than for 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, which play a role in pain modulation. Therefore, we think 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. It also assists in treating nerve-related pain, such as sciatica or singles. 

Which conditions respond to amitriptyline? 

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

  • Nerve inflammation due to conditions such as diabetes
  • Chronic musculoskeletal conditions such as arthritis or chronic shoulder or lower back pain. Amitriptyline is 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.

A recent study suggested some certainty of the effectiveness of amitriptyline for nerve pain but not so much for a pinched nerve. 

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 that used for depression.

It is important to titrate the dose of amitriptyline, meaning that you start low and slowly increase as tolerated. Generally, titrating the dose will reduce side effects. Overall, the dose of amitriptyline ranges from 20 to 75mg daily. The maximal dose of amitriptyline for pain is about 100mg daily. Anything above 100mg is probably not effective for pain. 

A recent study suggested doses of 50-75mg for pain conditions. 

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

Amitriptyline for pain: adverse effects

Generally, side effects are common when taking amitriptyline for pain. However, as the dose is lower than 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
  • 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, a lower dose of amitriptyline for chronic pain has fewer side effects.

Precautions and contraindications

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

Amitriptyline can make you excessively tired, so you should avoid driving or operating dangerous equipment if you are feeling fatigued.

Finally, it would be best if you were careful with alcohol as the effects of alcohol can be magnified while on this drug. Also, you should inform your doctor if you take other medications such as thyroxine, other anti-depressants, and certain analgesics such as tramadol.

Frequently asked questions about amitriptyline for pain

How does amitriptyline work for nerve pain? 

We don’t know exactly. Amitriptyline stops the nervous system’s reabsorption of serotonin and noradrenaline. Therefore, we suspect it works by increasing the concentration of these hormones, settling the nerves’ sensitivity, and thereby reducing nerve pain. This mechanism differs from that in depression as the dose is much lower. 

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.

Is 10mg of amitriptyline enough for nerve pain? 

Ten mg is a low dose. Generally, we advise a 20-50mg dose for nerve pain, although the dose also depends on side effects. Some people can only tolerate a 10mg dose. 

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 impact.

Is amitriptyline addictive?

No. However, it is vital that you stop amitriptyline slowly for about a month. Generally, we suggest reducing the dose by 1/2 for two weeks and then by 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. Rest can improve pain. However, 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, you should take this medication for at least three months.

Can I take ibuprofen with amitriptyline? 

Yes. Ibuprofen or other NSAIDs reduce inflammation and improve pain in many musculoskeletal problems. It is generally safe to take these two tablets together.

What painkillers can I take with amitriptyline? 

You can take other painkillers with different mechanisms of action. Examples include NSAIDs such as ibuprofen, paracetamol and opioids such as codeine. However, it would be best if you were cautious of adding other nerve pain medications such as duloxetine, gabapentin or pregabalin. 

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.

What can I take instead of amitriptyline for nerve pain? 

box of pregabalin

Generally, we consider other medications if patients cannot tolerate Amitriptyline for pain. However, sometimes, people take alternative drugs.

Duloxetine 

This drug is a different antidepressant that works on other brain and spinal cord receptors. It increases 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.

A recent study found that Duloxetine was moderately effective for chronic low back pain, knee arthritis and nerve pain. Another study found that Duloxetine was probably the most effective drug for chronic pain.

We used a dose of 30-60mg for a few months. It would be best to take Duloxetine with food or water, but don’t break open the capsule.

Common side effects include drowsiness, stomach irritability and an increase in anxiety.

Pregabalin or Gabapentin

We know these drugs by their common brand names, Neurontin or Lyrica. Neurontin is an anticonvulsant drug used to prevent seizures. Recent studies suggest it is also effective for pain. Nevertheless, it has significant side effects, such as drowsiness. As such, we use Lyrica less frequently for pain.

A recent review of Gabapentin vs Pregabalin found that Pregabalin was more effective with fewer side effects. Moreover, multiple prescriptions of Gabapentin for chronic low back pain were associated with an increased risk of dementia. 

Which is better for pain, gabapentin or amitriptyline? 

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

Amitriptyline and gabapentin: Can I take these medications together? 

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

Final word from Sportdoctorlondon about Amitriptyline for pain 

We think Amitriptyline suits chronic pain such as nerve trapping or 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.

Recent evidence suggests that Duloxetine is a good alternative for chronic low back pain, nerve pain and knee osteoarthritis. 

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