Back & Neck Pain Treatment What to Know About Amitriptyline A tricyclic antidepressant approved for treating symptoms of depression By Anne Asher, CPT facebook linkedin Anne Asher, ACE-certified personal trainer, health coach, and orthopedic exercise specialist, is a back and neck pain expert. Learn about our editorial process Anne Asher, CPT Medically reviewed by Medically reviewed by Jason DelCollo, DO on December 02, 2020 Jason DelCollo, DO, is board-certified in family medicine and on the faculty of Philadelphia College of Osteopathic Medicine. Learn about our Medical Review Board Jason DelCollo, DO on December 02, 2020 Print Getty Images/clubfoto Table of Contents View All Table of Contents Uses Before Taking Dosage Side Effects Warnings and Interactions Amitriptyline is a prescription oral antidepressant medication that is also sometimes used off-label for treating a variety of conditions, including anxiety, obsessive-compulsive disorder, and prevention of neuropathic pain. The amitriptyline dosage for treating anxiety is generally lower than the dose used for treating depression. When you are taking amitriptyline, it's important that you tell your doctor and pharmacist about any other medication you are taking so you will not have a risk of amitriptyline interactions. Amitriptyline is listed as an essential medicine by the World Health Organization. Amitriptyline is a generic formulation, and it had previously also been manufactured under brand names, including Elavil and Endep, which have been discontinued. These drugs were not withdrawn for reasons of safety or effectiveness. Uses Amitriptyline is approved by the Food and Drug Administration (FDA) for treating symptoms of depression. According to the manufacturer, amitriptyline is more effective for the treatment of endogenous depression (that which is caused by a genetic or biological factor) than for depression caused by external factors. This medication is meant to be taken every day for the prevention of depressive symptoms. People usually have to take it for four to six weeks before seeing improvement in their symptoms. Symptoms of depression can include: Sadness or hopelessness Loss of interest in activities Lack of motivation Crying Withdrawal from others Irritability Excessive sleeping or insomnia Changes in appetite Thinking about suicide Unexplained pain Amitriptyline increases the action of norepinephrine and serotonin, neurotransmitters that play a role in modulating pain and mood. Specifically, amitriptyline prevents termination of the action of these neurotransmitters by preventing their uptake into membrane receptors. Off-Label Uses Amitriptyline is commonly prescribed off-label for a number of uses. These are generally chronic conditions that require consistent, long-term management. Conditions that are often treated with amitriptyline include: Generalized anxiety disorder Pain associated with neuropathy, fibromyalgia, postherpetic neuralgia, or central nervous system disorders Migraine prevention Insomnia Panic attacks Obsessive-compulsive disorder Post-traumatic stress disorder (PTSD) Bulimia Sialorrhea (excessive drooling) As with the treatment of depression, amitriptyline is not expected to alleviate any of these conditions immediately when it is used off-label. It may take weeks for symptoms to begin to improve. Before Taking Amitriptyline is considered a medication that's used for palliative care. It is a first-line agent for the treatment of depression, which means that you can be prescribed this medication even if you have not tried any other treatments. It also isn't necessary that you try any other prescriptions before using amitriptyline off-label. Amitriptyline drug interactions, as well as certain medical conditions, need to be taken into account when considering treatment with this drug. Precautions and Contraindications Amitriptyline can cause sleepiness. As you are adjusting to amitriptyline, it's important that you avoid driving or using dangerous equipment until you can assess the effect it is having on you during the day. Amitriptyline is not FDA-approved for children under age 12. Amitriptyline should not be used if you: Have had an adverse reaction to it in the past Are recovering from a heart attack Have cardiac arrhythmia or QT prolongation on your electrocardiogram (EKG) Have bipolar disorder (the drug increases the risk of manic episodes) Your doctor will weigh the pros and cons of this medication before prescribing it to you if you: Are pregnant, plan to be pregnant, or are nursing Have wide-angle glaucoma Have a history of suicidal ideation or a suicide attempt, as amitriptyline has been associated with a risk of suicide Have schizophrenia (due to the potential effect of worsening symptoms) Have recurrent seizures Are at risk of a heart attack or stroke Other Tricyclic Antidepressants Due to its molecular structure, amitriptyline is described as a tricyclic antidepressant. Some other tricyclic antidepressants include: Nortriptyline Imipramine Desipramine Doxepin Amoxapine Other Antidepressants Other antidepressant classes include monoamine oxidase inhibitors (MAOIs), such as selegiline and rasagiline, and selective serotonin reuptake inhibitors (SSRIs), such as sertraline, fluoxetine, and paroxetine. In general, it is not always safe to combine different classes of antidepressants, but your doctor may prescribe more than one antidepressant for you under exceptional circumstances. Dosage Amitriptyline comes in tablet form and is available in doses of 10 milligrams (mg), 25 mg, 50 mg, 75 mg, 100 mg, and 150 mg. For treatment of depression, the medication is usually started at a dose between 50 mg and 100 mg per day. If necessary, your dose may be increased by 25 mg every three to seven days to a total of 150 mg per day. The standard maintenance dose of amitriptyline for the treatment of depression is 75 mg per day, either once at bedtime, or divided into two doses per day. Modifications According to the package label, hospitalized patients may require 100 mg a day initially. This can be increased gradually to 200 mg or 300 mg per day if necessary. Adolescents between the age of 12 and 18 and elderly adults should start at a lower dose of approximately 30 mg per day, with a target dose of 60 mg per day. If you have liver disease, your doctor may prescribe a lower dose of amitriptyline for you. Follow your prescriber's instructions and never alter your dose on your own. Off-Label Dose When used off-label, amitriptyline is started at a lower dose than when it is used as an antidepressant—typically at a dose of 10 mg or 20 mg per day. If needed, this dose can be slowly increased under the guidance of your physician. The amitriptyline dosage for anxiety may also be modified in light of amitriptyline drug interactions. Sometimes amitriptyline is used when you have depression and pain. In these situations, the dosing would follow the recommendations for treatment of depression, rather than treatment of pain. The Link Between Depression and Chronic Pain How to Take and Store Amitriptyline is taken by mouth, initially in divided doses, but can be taken once per day when the target dose is established. If you are taking your entire dose of amitriptyline at once, it should be at bedtime, and if you are taking it in divided doses, one of the doses should be taken at bedtime. Amitriptyline should be stored in the original container at 68 to 77 degrees. If necessary, you can place your medication in a pillbox to help you manage your medication schedule. Side Effects Amitriptyline can cause side effects when it is used for the treatment of depression or for an off-label indication. Sometimes the side effects are temporary and may resolve after a few weeks, but you might continue to have side effects even after months of using it. Rarely, side effects emerge after months or even years of using this drug without side effects. Some side effects are dose-related and might improve if your doctor reduces your dose. Common Common side effects of amitriptyline include: Headaches Lightheadedness, dizziness, or orthostatic hypotension (low blood pressure when standing) Increased appetite and weight gain (the weight gain can be more than what you would expect from the increased appetite) Dry mouth or mouth sores Diminished sex drive or impotence Sleepiness or drowsiness Using amitriptyline at night may alleviate sleepiness, but some people continue to feel drowsy during the day, even after a full night's sleep. Severe Amitriptyline may cause severe adverse effects. If you experience serious side effects, your doctor will likely give you instructions to discontinue taking amitriptyline. Severe side effects of amitriptyline include: Suicidal thinking, especially among adolescents Mood changes Sleep disturbances Anxiety Agitation Seizures Acute angle-closure glaucoma Increased risk of bleeding Black Box Warning All patients being treated with antidepressants for any indication should be monitored appropriately and observed closely for clinical worsening, suicidality, and unusual changes in behavior, especially during the initial few months of a course of drug therapy. Rare Side Effects Amitriptyline has also been associated with severe side effects that occur very infrequently. Rare side effects include: Allergic reaction: skin rash, swelling, and/or trouble breathing Neuroleptic malignant syndrome: fever, muscle rigidity, confusion, severe constipation, increased heart rate, and sweating Warnings and Interactions Withdrawal from this drug can cause nausea, headaches, irritability, and sleep disturbances. Rarely, mania can occur after abruptly stopping this medication. If you are going to stop taking amitriptyline, it's important that you discuss a tapering schedule with your doctor. Amitriptyline can interact with a number of prescription medications. This medication is especially dangerous when combined with other antidepressants, such as other tricyclic antidepressants or MAOIs. If you are replacing one antidepressant with another, your doctor will give you detailed instructions regarding decreasing or stopping the medication you are already taking before you start the other. Some common medications that interact with amitriptyline include: Celexa (citalopram) Cymbalta (duloxetine) Desyrel (trazodone) Flexeril (cyclobenzaprine) Lyrica (pregabalin) Prozac (fluoxetine) Synthroid (levothyroxine) Topamax (topiramate) Ultram (tramadol) Xanax (alprazolam) Zoloft (sertraline) How to Take Amitriptyline for Pain Was this page helpful? Thanks for your feedback! Sign up for our Health Tip of the Day newsletter, and receive daily tips that will help you live your healthiest life. Sign Up You're in! Thank you, {{form.email}}, for signing up. There was an error. Please try again. What are your concerns? Other Inaccurate Hard to Understand Submit Article Sources Verywell Health uses only high-quality sources, including peer-reviewed studies, to support the facts within our articles. Read our editorial process to learn more about how we fact-check and keep our content accurate, reliable, and trustworthy. Dean L. Amitriptyline Therapy and CYP2D6 and CYP2C19 Genotype. In: Pratt VM, McLeod HL, Rubinstein WS, et al., eds. Medical Genetics Summaries. Bethesda (MD): National Center for Biotechnology Information (US); March 23, 2017 World Health Organization Model List of Essential Medicines. 21st list. 2019. Food and Drug Administration. FDA-Approved Drugs. Federal Register. The Daily Journal of the United States Government. Determination that ELAVIL (amitriptyline hydrochloride) oral tablets, 10, 25, 50, 75, 100, and 150 milligrams, were not withdrawn from sale for reasons of safety or effectiveness. October 23, 2017. Antidepressant Agents. In: LiverTox: Clinical and Research Information on Drug-Induced Liver Injury. Bethesda (MD): National Institute of Diabetes and Digestive and Kidney Diseases; April 27, 2018. Food and Drug Administration. Amitriptyline label. May 28, 2014. Tse L, Barr AM, Scarapicchia V, Vila-rodriguez F. Neuroleptic malignant syndrome: A review from a clinically oriented perspective. Curr Neuropharmacol. 2015;13(3):395-406.doi:10.2174/1570159X13999150424113345 Additional Reading Food and Drug Administration. Amitriptyline Label. Updated May 28, 2014. Thour Amit, Marwaha, Raman. Amitriptyline. Stat Pearls, October 12, 2019.