Interactive Headache Flowchart

Amitriptyline (or Nortriptyline)

 

Why take it?

Tricyclic antidepressants were developed in the 1960s, and were first used for migraines in the 1970s. Medications such as amitriptiline, nortriptiline or dosulepin are now as commonly used for prevention of headaches and nerve pain. The doses used in migraine are generally much lower than for depression, so that side effects are much less too.

Serotonin is a chemical occurring in the body, which has a role in migraine and in depression as well as in how the brain handles pain.

 

Many doctors prescribe Amitriptyline, however it stays in the body for longer than Nortriptyline, and is more likely to produce side effects. A patient could start with Amitriptyline and then swap to Nortriptyline if side effects occur.

 

How to take it

Tricyclics are taken in the evening, before going to bed. Amitriptiline or Nortriptyline should be started at 10-25 mg at night, and increased by 10mg every 5-7 days until the headaches settle. Some people require 70-100 mg. Some patients with chronic daily headache may only respond to doses as high as 150-200 mg daily.

Some patients feel drowsy in the morning (much less common with Nortriptyline than Amitriptyline). By taking the medication earlier in the evening, this can be reduced. Some doctors recommend taking these drugs 12 hours before the patient wishes to get out of bed.

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How long to take it

Once a dose has been arrived at that controls the headaches, that dose should be taken for at least 6-12 months. The drug is then withdrawn slowly over 3 months. If the headaches return, the dose should be slowly increased until the headaches have settled, and further attempts should be made to reduce the dose after 4 months.

 

Side effects

The commonest side effects are drowsiness, dry eyes, and dry mouth and blurred vision, difficulty passing water and tiredness. These side effects are more likely to occur with higher doses, but often settle down over 3-4 weeks as the body gets used to the medication. The slow rate of increase of the medication recommended also reduces side effects.

 

If fatigue is present on waking in the morning, the evening dose may be taken earlier-up to 3 hours before going to bed to minimise side effects the following morning.

 

Nortriptyline may produce drowsiness that may affect driving, and may increase the sedating effects of alcohol.

 

Nortriptyline should not be taken by people who have recently suffered a heart attack, those with irregular heart rhythms or heart block.

 

There are a number of rarer side effects, and a patient should see their GP if they feel that Nortriptyline doesn’t agree with them. It may be necessary to do blood tests, including blood counts, blood chemistry and liver tests.

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This page has been adapted from a leaflet produced by the Neurology Department of Salford Royal Hospital