Amitriptyline (Migraine Prophylaxis) (Amitriptyline hydrochloride)
Also sold as: Tryptomer, Elavil, Amitone
Pregnancy
Cat C
Lactation
Caution
Schedule
H
Forms
Tablet (10mg, 25mg, 50mg, 75mg)
Indications
- Migraine prophylaxis
- Tension-type headache prophylaxis
- Chronic pain syndromes
- Fibromyalgia
- Irritable bowel syndrome (off-label)
- Depression (separate indication — different dosing)
Adult Dosing
Migraine prophylaxis
10–25 mg at bedtime initially
Increase by 10–25 mg every 2–4 weeks to effective dose; usual effective range 50–75 mg at bedtime (some patients require up to 150 mg)
Start very low (10 mg) and titrate very slowly to minimise side effects. Prophylactic effect takes 4–6 weeks at adequate dose. Review at 3–6 months.
Tension-type headache prophylaxis
10–75 mg at bedtime
Titrate slowly to effective dose
Chronic pain / fibromyalgia / neuropathic pain
10–75 mg at bedtime
Lower doses (10–25 mg) often effective for pain modulation
Pain-modulating doses are much lower than antidepressant doses. Explain this to patients to improve acceptance.
Pediatric Dosing
Evidence limited in paediatric migraine. Not recommended under 12 years for this indication. Use with caution.
Renal Dose Adjustment
| CrCl / eGFR | Dose Adjustment |
|---|---|
| Mild-moderate impairment | No dose adjustment required |
| Severe impairment | Use with caution |
Hepatic Adjustment
Significant hepatic metabolism. Severe hepatic impairment: avoid or use lowest possible dose with close monitoring (risk of accumulation and toxicity).
Pregnancy & Lactation
Pregnancy: Category C
Limited data. Neonatal withdrawal syndrome reported with third-trimester use. Generally avoided in pregnancy; discuss risk-benefit with specialist. Preferred: propranolol or topiramate (noting topiramate is category D).
Lactation: Caution
Excreted in breast milk. Monitor infant for sedation and poor feeding. Not preferred during breastfeeding; consider alternatives.
Top Drug Interactions
| Interacting Drug | Effect | Severity |
|---|---|---|
| MAOIs (phenelzine, tranylcypromine, isocarboxazid) | Potentially fatal serotonin syndrome — absolutely contraindicated; allow 14 days washout | Major |
| SSRIs (fluoxetine, paroxetine) | CYP2D6 inhibition markedly increases amitriptyline levels; also additive serotonin syndrome risk | Major |
| Tramadol | Increased seizure risk and serotonin syndrome — avoid combination | Major |
| QT-prolonging drugs (erythromycin, haloperidol, amiodarone, methadone) | Additive QT prolongation — risk of torsades de pointes | Major |
| Alcohol | Enhanced CNS depression and sedation | Moderate |
| Anticholinergic drugs (oxybutynin, antihistamines) | Additive anticholinergic effects — dry mouth, urinary retention, constipation, confusion (especially in elderly) | Moderate |
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Side Effects
Common
- Sedation / drowsiness (use at bedtime — actually beneficial for sleep)
- Dry mouth
- Constipation
- Weight gain
- Blurred vision
- Urinary hesitancy or retention
- Orthostatic hypotension
Serious / Discontinue If
- QT prolongation and cardiac arrhythmias (especially in overdose — extremely dangerous)
- Serotonin syndrome (with interacting serotonergic drugs)
- Urinary retention (acute — especially in elderly men with prostatic hypertrophy)
- Acute angle-closure glaucoma
- Suicidal ideation (class warning — monitor closely in young adults)
- Seizures at higher doses
Contraindications
- Recent myocardial infarction
- Severe cardiac arrhythmias
- MAOIs within 14 days
- Acute angle-closure glaucoma
- Urinary retention or significant benign prostatic hypertrophy
- Known QT prolongation
Available Indian Brands
| Brand | Manufacturer | Price (approx) |
|---|---|---|
| Tryptomer 10mg | Merck | ₹18/10 tab |
| Amitone 10mg | Torrent | ₹15/10 tab |
| Elavil 25mg | Pfizer | ₹28/10 tab |
Monitoring Required
- ECG before initiation in patients >40 years or with cardiac risk factors (QT assessment)
- Blood pressure (orthostatic hypotension)
- Weight
- Intraocular pressure if glaucoma risk
- Urinary symptoms in elderly men
- Migraine diary — assess frequency reduction at 6–8 weeks
Patient Counseling Points
- Take this medicine at bedtime — the sedation is helpful for sleep and reduces daytime drowsiness
- Start with 10 mg and increase slowly — your doctor will guide the titration
- Dry mouth, constipation, and weight gain are common — stay hydrated and eat a high-fibre diet
- This medicine takes 4–6 weeks to reduce headache frequency — do not stop early if you do not notice immediate benefit
- Do not drive or operate machinery until you know how this medicine affects you
- Avoid alcohol — it worsens the sedation
- This is not an antidepressant dose — it is being prescribed specifically to prevent headaches at a much lower dose
- Overdose is extremely dangerous — keep out of reach of children; take only as prescribed
- Do not stop suddenly — taper under medical guidance
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Clinically reviewed by: Dr. Priya Nair, DM Neurology, DM Neurology, Senior Consultant Neurologist
Last reviewed: 2026-04-01
References
- Jackson JL, et al. Tricyclic antidepressants and headaches. BMJ. 2010;341:c5222.
- Amitriptyline prescribing information — Merck India.
- Indian Headache Society Guidelines 2021.