Elavil Dosage and How Amitriptyline Works for Pain

Elavil (amitriptyline) is a tricyclic antidepressant that's sometimes prescribed off-label for back pain, neck pain, and migraines. The Elavil dosage for pain is different than it is for depression, and it may depend on exactly where your pain is, as well. Because Elavil works on the nervous system, it's more effective for neuropathic pain—originating in nerves—than for pain caused by soft tissues or musculoskeletal problems.

Pills of different shapes, colors and sizes
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What is Amitriptyline Used For?

Amitriptyline is approved by the Food and Drug Administration (FDA) for one use only: major depression. It's also used off-label (without specific FDA approval) for several types of chronic (long-lasting) pain that are related to nerve damage or dysfunction, including:

  • Diabetic neuropathy: Nerve damage due to elevated blood sugar levels can cause pain and numbness. The most common sites are the limbs and extremities but it can strike elsewhere as well.
  • Postherpetic neuralgia (PHN): A complication of shingles, PHN can last for months or years after the shingles rash clears up and can be debilitating. The rash and continuing pain typically occur on one side of the body only, and across the back and torso, neck and shoulder, or face.
  • Migraines: Recurring headaches that throb or pulse and can be severe, migraines may also involve sensitivities to light and sound as well as an aura, which is an abnormal sensory phenomenon like seeing flashing lights or feeling like you're being touched.
  • Fibromyalgia: This often debilitating widespread pain condition is believed to involve abnormal pain perception by the central nervous system. Other symptoms include fatigue, cognitive dysfunction, and unrefreshing sleep.

Antidepressants are effective at treating pain because of their impact on neurotransmitters (chemical messengers in the brain and nervous system). They're believed to change the activity of the neurotransmitters serotonin and norepinephrine, which are involved in pain processing. Antidepressants may be prescribed alone or alongside traditional painkillers.

Chronic Back or Neck Pain

Healthcare products may opt to prescribe amitriptyline for other causes of pain, as well, including chronic back and neck pain due to disease or injury. Antidepressants like amitriptyline are not typically the first medications healthcare providers prescribe for these types of pain, but they're often used when other treatments haven't been successful.

While a fair amount of research supports the use of amitriptyline and other tricyclic antidepressants for neuropathic pain and migraine, evidence thus far is lacking when it comes to chronic neck or back pain.

A review of studies published in 2021 found that tricyclics in general haven't been shown to alleviate back pain. However, the reviewers considered the evidence of generally low quality, so much work remains to be done on this topic.

Other Off-Label Uses

Additional off-label uses of amitriptyline include:

  • Social anxiety disorder
  • Panic disorder
  • Insomnia
  • Bulimia, as an add-on treatment
  • Bedwetting
  • Persistent hiccups

Dosage

The appropriate dosages of amitriptyline for treating chronic back or neck pain haven't been determined, but healthcare providers can use those that have been established for pain conditions as a guideline. As a general rule, the dosage for pain is lower than it is for depression.

Elavil Dosage Guide

Amitriptyline treatment is typically titrated, meaning that you start with a smaller dose and gradually increase the dose until the desired effect is achieved, which can help avoid significant side effects.

When used for the treatment of neuropathic pain, many healthcare providers will start at a dose of 25 milligrams (mg) and gradually increase the amount over the course of several weeks or months. People who are smaller or frail may be started at 10 mg.

ELAVIL (AMITRIPTYLINE) RECOMMENDED DAILY DOSAGE
PAIN CONDITIONS LOW MAX 
Diabetic neuropathy 25mg 100mg
Postherpetic neuralgia  25mg 125mg
Migraine  25mg 100mg
Fibromyalgia  10mg 50mg
Source: Prescribers' Digital Reference

Warnings and Contraindications

Older adults may have a strong response to amitriptyline and, therefore, need smaller doses. Amitriptyline is often avoided in people over age 60 because the drug may increase their risk of cardiac arrhythmia (abnormal heart rhythm).

Amitriptyline is also contraindicated for use in people with a known allergy to the drug or any inactive ingredient in it. It should also never be used in people who take monoamine oxidase inhibitors (MAOIs) for depression.

All antidepressants carry a black box warning advising consumers of the risk of suicidal thoughts in children, adolescents, and young adults who take the drug. For this reason, they're only used to treat pain in younger people if the benefits are believed to outweigh the risks. However, studies show amitriptyline may be one of the least likely antidepressants to cause this side effect.

How to Take and Store

Amitriptyline comes in tablet form. The drug is generally taken at night to avoid dizziness, drowsiness, and other central nervous system side effects.

The pill should be swallowed whole. Do not break, split, crush, or chew the tablet as it can affect its absorption of the drug in the gut. There are no food restrictions; amitriptyline can be taken with or without food.

If you miss a dose, take it as soon as you remember. If it is near the time of your next dose, simply skip the original dose and continue as normal. Do not double the dose to catch up.

Amitriptyline can be stored safely at room temperature. Keep the tablets in their original light-resistant container, and avoid storing them on a sunny windowsill or in your glove compartment. Discard any medications that have expired.

Amitriptyline Side Effects

You should not stop taking amitriptyline without talking to your healthcare provider first. Because the drug builds up in your system, the sudden discontinuation can lead to withdrawal symptoms, sometimes severe. These include:

  • Dizziness
  • Headaches
  • Nausea or vomiting
  • Fatigue
  • Loss of appetite
  • Diarrhea
  • Joint or muscle aches
  • Anxiety
  • Irritability
  • Loss of concentration
  • Light and sound sensitivity
  • Mood swings

To avoid withdrawal, your healthcare provider may gradually taper the drug over the course of weeks or months, depending on the dose and how long you've been taking amitriptyline.

Overdose

As with any medication, the risk of an amitriptyline overdose is real. One of the best ways to avoid an overdose is to recognize the signs.

Symptoms of amitriptyline overdose include:

  • Lightheadedness
  • Drowsiness
  • Fainting
  • Confusion
  • Problems concentrating
  • Vomiting
  • High fever
  • Profuse sweating
  • Feeling excessively hot or cold
  • Cold body temperature
  • Stiff or rigid muscles
  • Irregular heartbeat
  • Seizures or convulsions
  • Coma

If you think you or someone you know has overdosed on amitryptiline, contact Poison Control immediately at 1-800-222-1222.

Frequently Asked Questions

How should I increase my Elavil dosage?

When first starting on this drug or moving up to a higher dosage, you should always increase your Elavil dosage gradually. Your healthcare provider can advise you on when and by how much to increase it, and it's important that you follow those instructions to the letter.

What should I know about Elavil and suicide?

Elavil, and all antidepressants, may increase the risk of suicidal thoughts and behaviors. While this risk appears to be highest in people under age 24, it may impact the mental health of anyone who takes it. The risk is greatest when you first start the drug, whenever you increase your Elavil dosage, and whenever you reduce your dosage.

If you are having suicidal thoughts, contact the National Suicide Prevention Lifeline at 1-800-273-8255 for support and assistance from a trained counselor. If you or a loved one are in immediate danger, call 911.

For more mental health resources, see our National Helpline Database.


What is the average dosage range for Elavil?

For depression, the average Elavil dosage range is 50 mg to 100 mg per day. For most pain conditions, it's 25 mg to 100 mg or 125 mg a day, while for fibromyalgia it's lower—10 mg to 50 mg a day. The maximum dosage is considered 150 mg daily.

A Word From Verywell

If you have neuropathic pain, migraine, or chronic back or neck pain that hasn't responded to other treatments, your healthcare provider may suggest amitriptyline. Be sure you understand the potential benefits and risks of this medication and are alert to possible side effects before you start taking it. It's vital to follow Elavil dosage instructions and titrate up as directed by your healthcare provider.

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Article Sources
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