There is anecdotal evidence that large doses of amitriptyline can cause a ‘high’ or hallucinations; however, there have been no formalized studies around this. Trying to reach these large doses is extremely dangerous and can significantly worsen side effects as well as lead to a potentially fatal overdose. Signs of an amitriptyline overdose can include:
- Fast or uneven heartbeat
- Enlarged pupils
- Muscle stiffness
Despite the potential for a high, addiction to amitriptyline is not widely reported, probably because extremely high doses would be required to get an effect.
On the other hand, as is the case with several antidepressants, discontinuation of Elavil can cause withdrawal effects if done too suddenly. The most common withdrawal symptoms for amitriptyline are headaches, fatigue and dizziness. However, other effects have been noted including:
- Anger and irritation
- Body aches
- Flu-like symptoms
- Hypersensitivity to light and/or sound
You are more likely to experience withdrawal symptoms from amitriptyline if you were taking the medication for a long time (i.e., years) rather than a shorter course of treatment. You may also experience worse symptoms if you were taking a higher dose.
Always consult with your doctor before coming off Elavil, and reduce your dose very gradually. This will make the process easier and cause less shock to your central nervous system than quitting cold turkey. The weaning period will depend on how long you had been taking Elavil and at what dosage, with the decrease being slower and more gradual if your body has been used to it for a long time.
- Amitriptyline–preventive treatment of migraine headache?
- The “Skinny” on Obesity and Migraine
- Migraine and Obesity
- What is “Obesity”?
- The Link Between Migraine and Obesity
- Understanding the Relationship
- Treatment Considerations
- Get Moving: The Benefits of Aerobic Exercise
- Diets for Migraine
- Further Reading
Amitriptyline–preventive treatment of migraine headache?
Elavil, or now commonly called by the generic name, amitriptyline, came out in 1961 and is one of the oldest drugs used for migraine prevention currently. Although originally intended for treatment of depression by the FDA at doses of 75-150 mg, headache doctors successfully use lower doses such as 10-30 milligrams taken at bedtime.
This is an article by Britt Talley Daniel MD, member of the American Academy of Neurology, the American Headache Society, migraine textbook author, and blogger.
Amitriptyline-preventive treatment of migraine? Yes, the American Academy of Neurology current update for pharmacologic treatment for episodic migraine prevention for adults states that Amitriptyline has “Moderate Evidence” of treatment success and “should be considered for migraine prevention. (Level B).
How to dose amitriptyline.
Psychiatric level treatment of 75-150 mg for depression may have side effects of early morning drowsiness, a dry mouth, constipation, and possible weight gain.
However, using 10-30 mg of amitriptyline at night for headache doesn’t usually cause weight gain and the side effects are more tolerable.
Early morning drowsiness may be a limiting side effect. If this occurs, the patient should try starting at one half of 10 mg or 5 mg for a few weeks and then advancing to 10 mg.
Taking the drug earlier in the evening may also be helpful. That is, if the patient goes sleep at 10:00 they would take amitriptyline at 9 PM.
Amitriptyline success alone
Amitriptyline alone, usually given at night, reduces migraine by about 30%.
Amitriptyline helps with sleep.
The drug is useful for migraine patients also because they commonly have psychiatric illness such as depression (50% comorbid with migraine) or generalized anxiety disorder (GAD) and panic disorder both of which are 40 % comorbid with migraine.
Depression and GAD have the common cardinal symptom of insomnia and amitriptyline is the only recommended drug for migraine prevention which really helps with sleep.
Amitriptyline is not addictive.
Amitriptyline is a class 2 drug and is not addictive. Class 4 drugs are narcotics like the opioid narcotic hydrocodone which is addictive.
Amitriptyline works on dopamine receptors to help migraine and also puts patients into deep levels of sleep. Sleep is good for migraine and many migraine patients don’t sleep well.
Research sleep studies on migraine patients show that they are usually in light sleep (stage 1 or 2 sleep). However, treated with amitriptyline migraine patients may go into deeper stages of sleep such as stage 3 or 4 which is good for headache.
Sleep has 4 stages, stage 1 being light sleep and stage 4 being deep sleep.
Amitriptyline helps nighttime migraine.
My personal medical experience is that amitriptyline is also a useful drug for nocturnal, middle of the night, and early morning “wake up” headaches.
Early morning wake up headaches are a very common problem with many migraine patients. I encourage them to keep their acute therapy migraine drug, probably a triptan at bedside with a glass of water so they can just roll over, take their medicine, and go back to sleep.
A dreadful mistake for many migraine patients is to not treat at the onset of their migraine and then have to suffer a disabling migraine all that same day.
Amitriptyline treats tension-type headache also.
Amitriptyline has a recommendation for use with tension-type headache at a dose of 75-150 mg. Migraine patients may also have Tension Type Headache which commonly has a physical finding of muscle tenderness of the head when examined by the doctor. Amitriptyline helps with muscle tenderness.
Amitriptyline is a very inexpensive drug.
Another good aspect of the drug is that it is very cheap. In Dallas Walmart sells it for $3-4 and I encourage patients to pay cash for it because their co-pay card price for other migraine preventive drugs may be $5-20. Sometimes it is free with certain insurances.
Aimovig, one of the new CGRP drugs for migraine, costs $540 per month without insurance.
Amitriptyline is a very small pill.
I’ve had patients, particularly adolescents, who couldn’t take certain pills and referred to them as “that horse pill.” 10 mg is a very tiny, easy to swallow pill.
Consider staying on amitriptyline when you start one of the new CGRP drugs.
Headache doctors started using Aimovig, the first CGRP drug for migraine, in July 2018.
I personally used a lot of amitriptyline before that time, often with other preventive migraine drugs like Depakote, propranolol, or topiramate, but I have always advised patients to stay on their previous preventive drugs when they start one of the new CGRP drugs. CGRP drugs don’t help sleeping.
Then, many patients will stay on amitriptyline and their CGRP drug to continue sleeping well.
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Britt Talley Daniel MD
The “Skinny” on Obesity and Migraine
Thank you to Lee Peterlin, DO; Simona Sacco, MD; Andrea Harriott, MD for their contributions to this spotlight.
Migraine and Obesity
Migraine and obesity are common conditions that have a major impact on patients, their families, and society. Over the past two decades, scientists have figured out that the chances of having migraine are increased in those who are obese and that this risk increases as someone gains weight and changes physical stature from normal weight to overweight to obese. They’ve also learned that migraine patients who are obese are more likely to develop a chronic attack pattern.
It’s important to understand that obesity does not cause migraine. Rather, it’s a risk factor, which means being obese makes it more likely you will have migraine. (Age is also a risk factor, but not a cause.) What’s more, doctors consider obesity a modifiable risk factor, one that can be changed (unlike age). So if you have migraine and are obese, think of it as a project that you, your doctors, and your nutritionist can work on together — as a team.
If you have migraine, knowing your obesity status may make it easier to choose migraine treatments that meet your needs. It can also
influence which drugs your doctor recommends to help you avoid gaining weight or to help you lose weight. The team approach is similar to patients with high cholesterol, who work on their own and with their doctors on exercise, diet, and medication choices to decrease the risk of heart attack and stroke. With migraine and obesity, the big difference is the ultimate goal: having fewer and less intense attacks.
What is “Obesity”?
Obesity means having too much fat tissue. But how much is too much? You might be surprised to learn that accurately measuring body fat can be both challenging and expensive. The good news is that there is a quick and inexpensive way to estimate obesity. It’s called the body mass index or BMI. BMI can be calculated using your height and body weight and applying a mathematical formula. The World Health Organization defines obesity as having a BMI of at least 30 (or at least 23 for people of Asian descent). See chart below.
|Table 1. Obesity Categories Based On The Body Mass Index (BMI)|
|Non-Asian Populations||Asian Populations⃰|
|BMI < 18.5||BMI <18.5||Underweight|
|BMI 18.5-24.9||BMI 18.5-22.9||Normal weight|
|BMI 25-29.9||BMI 23-24.9||Grade I obesity||Overweight|
|BMI 30-39.9||BMI 25-30||Grade II Obesity||Obese|
|BMI ≥ 40||BMI ≥ 30||Grade III Obesity||Morbid Obesity|
|⃰In 2000 the World Health Organization, the International Association for the Study of Obesity, and the International Obesity Task Force recommended that the BMI value of ≥23 represent overweight physical status and a BMI of ≥25 represent obesity in Asians. In 2004 the World Health Organization identified potential public health action points for a BMI between 23.0 – 27.5 in Asian populations; however, formal recommendations for obesity status, based on BMI cutoffs, were not made; and the WHO proposed that each country make decisions regarding BMI definitions at increased risk for its population.|
The Link Between Migraine and Obesity
The link between migraine and obesity has been studied for over 15 years, with more than a dozen studies conducted on patients of all ages and types. Taken as a whole, the evidence says that obesity raises the risk of having migraines as much as 50% — about the same amount as having heart disease or bipolar disorder. But the risk grows as obesity increases, and it’s almost 3-fold (275%) in patients with BMIs above 40.
Understanding the Relationship
Since the mid-1990s, experts have come to believe that fat is a highly active substance. In fact, fat tissue secretes a wide range of molecules that send signals to many other body parts and systems. In people who are obese, the extra fat cells tell the body to make inflammatory proteins. This new understanding of fat cells suggests that obesity keeps the body in a mild, but constant, state of inflammation.
We still don’t fully understand how migraine and body composition are related, but studies are underway. At present, it appears that a region of the brain (the hypothalamus) that controls hunger and neurotransmitters associated with migraine may play a key role. It’s also possible that obese people are more sensitive to stimulation.
Several obesity-related proteins are being studied for their role in migraine. Two of the most important are orexin and adipokines.
With orexin (which is also considered a hormone), studies in animals and humans indicate that it may be involved in many aspects of migraine. But study results have been inconsistent. Researchers, from Harvard University, now think they may have better luck with drugs that have been fine-tuned to work on orexin.
Adipokines are proteins found in fat cells called adipocytes. A few studies have shown that, in some migraine patients, levels of certain adipokines (e.g., adiponectin, leptin, and resistin) are elevated during and between attacks. An author of this article (BLP) was the first to hypothesize a relationship between any adipokine and migraine. A high-quality scientific review of adipokines and migraine was recently published. Refer to the Further Reading section (below).
Check the Label
If you struggle with your weight and have migraine, talk with your doctor about the effect of your medications on weight. Weight gain is among one the most common reasons for a patient to reject trying and to stop a migraine prophylactic medication — even when it has been effective.
As this table shows, many of the most common migraine medications can cause weight gain. But some are weight-neutral, and a few may cause weight loss.
|Weight and Migraine Preventative Medications|
|Drug Class/drug||Weight Change|
|Calcium Channel Blockers|
|Angiotensin Receptor Blockers|
|Serotonin (5HT) antagonists|
Get Moving: The Benefits of Aerobic Exercise
Exercise and migraines have a strong, two-way relationship. A lack of exercise increases the risk of having migraine attacks by approximately 21% in adults and 50% in adolescents. But regular and consistent aerobic exercise not only reduces the chances of having migraine attacks, it also makes them less painful and disabling when they do occur. Although it’s hard to generalize, those who regularly exercise for about 40 or 50 minutes on 3 days per week seem to enjoy the most benefits.
Diets for Migraine
In 1873, Dr. John Fothergill — an English physician, plant collector, philanthropist — was quite certain that “nothing more speedily and effectually give the sick headache ”. But by 1925, other experts were confident he was wrong; the sole cause of migraine was an inability to metabolize protein.
Physicians have been debating for over a century whether abnormalities in fat or protein metabolism contribute to migraine. They’ve also argued about which diets can help people with migraine. The debate rages on today, at least partially fueled by conflicting findings from research that is not always of the highest quality. But while you can be sure that there’s no such thing as “The Migraine Diet,” some studies are hinting that there may be benefits from low-fat and high-protein diets, not to mention diets high in specific fatty acids.
Here’s a brief review of what we know so far.
Some evidence suggests that a low-fat diet can be good for people with migraine. In a study comparing a low-fat diet (i.e., less than 20% of total intake) with a standard diet in patients with episodic or chronic migraine, those who ate a low-fat diet had 64% fewer headache days per month after three months. The reduction in headache days for patients on the standard diet was only 8%. More research is needed to validate the use of a low-fat diet in those with migraine.
Low-carbohydrate (also known as ketogenic) diets generally limit the amount of carbohydrates to fewer than 20 grams per day. Early research in this area was not promising, but at least one study suggests the story is not yet over. In a group of overweight women with migraine, those who had a low-carbohydrate diet had 80% fewer attacks after the first month on the diet. After six months, the number of days with migraine was still 40% lower than it had been when starting the diet. Further research is needed to validate these findings.
Omega Fatty Acids
Omega fatty acids may affect the likelihood of having a migraine attack. Early research found that a diet low in omega-3 fatty acids tends to increase the number of attacks. But another study using supplements (i.e., not a diet) was unable to replicate those results. A newer, three-month study of adults with chronic tension-type headache or migraine — this time using a diet high in omega-3 and low in omega-6 fatty acids (think salmon and flaxseed) — found that the diet cut attack frequency by more than half (53%). Based on these encouraging results, it is possible that future research will reveal exciting possibilities in this area.
If you liked this section, check out the Migraine and Diet Spotlight On article by Drs. Halker, Ailani, and Dougherty. It nicely details and summarizes this data.
Currently, migraine is not an appropriate indication to pursue bariatric surgery. But if you qualify for other reasons and have the procedure, 3 studies suggest that you may end up with fewer and less intense migraine attacks. While these findings are encouraging, more studies are needed to clarify the possible benefits of bariatric surgery in migraine patients.
In summary, obesity increases the risk of migraine and this risk increases with increasing obesity status from normal weight to overweight to obese to morbidly obese. Several neurotransmitters, proteins, and molecules that participate in maintaining energy appear to be involved in migraine. Aerobic exercise is effective for migraine prevention, and low-fat or ketogenic diets may be effective; while not indicated for migraine alone, bariatric surgery may also be beneficial in reducing attack frequency and severity. Overall, and as for good health in general, it is important for those with migraine to maintain a healthy weight and to maintain healthy lifestyle choices in terms of both diet and exercise.