There really isn’t any shortage when it comes to finding those with Fibromyalgia who use Amitriptyline. In the years since it was first approved for use, its prescription has only ever increased. Whilst there are a great many individuals who do swear by its effectiveness at helping to ease chronic pain, there are just as many who find an abundance of side effects that limit their ability to use it. Once again, when it comes to fibromyalgia, we are left with something that can help a lot of individuals, but also something that doesn’t do a great deal for others: how familiar!
Medication isn’t something that we deal with here at The Fibro Guy. The purpose of this article is to give you a rundown on Amitriptyline and Fibromyalgia, and the current research behind it, helping you to make informed choices when consulting with your doctors.
In this article, let’s break down some of the research jargon, take a little dive into exploring its benefits and side effects, and look at why it may work for some, but not others.
What is Amitriptyline?
Amitriptyline is a tricyclic antidepressant type of medication, which in recent years, has started to be given to those with Fibromyalgia. First synthesized in the 1950s and approved for medical use in the USA in 1961 by the pharmaceutical company Sandoz, Amitriptyline is definitely a drug that took the world by storm.
Fun fact: Amitriptyline gets its name “tricyclic” from its chemical structure, which consists of three rings of atoms.
Despite Amitriptyline being used now for a number of years, the exact mechanism of how it works is still largely out for debate. However, just like general Anaesthesia, which has been used for nearly 200 years and gets used around 60,000 times per day in the states, we still don’t really know how it even works.
The leading theory on how Tricyclic antidepressants work is that they increase the levels of specific chemicals within the brain that are involved in regulating mood: chemicals like serotonin and norepinephrine. However, fairly recently actually, this main theory has come under a lot of scrutiny, when people realised that the old “chemical imbalance theory” had a grand total of 0 pieces of evidence to back it up. Somewhat alarming really, especially when you consider that 90% of the public believes that depression is caused by low serotonin levels or chemical imbalances.
Whilst Amitriptyline has been around for literal decades, it has usually only ever been used to treat various mental health conditions such as depression and anxiety. However, fairly recently even, it’s been found that Amitriptyline is somewhat effective at reducing nerve pain and even some Fibromyalgia associated pain.
With a long history and a relatively safe drug profile, Amitriptyline soon became a staple in many Doctors’ offices around the world. However, in 2000, the brand name form of amitriptyline known simply as Elavil, was discontinued by the Food and Drug Administration (FDA). Whilst the exact reason that this happened is not really known, it is speculated to do with the side effects. Whilst the brand name drug Amitriptyline is no longer available, Amitriptyline as a generic drug is still very much available. Sometime later in 2017, the FDA stated that the decision to discontinue the drug wasn’t anything to do with its safety or effectiveness.
Amitriptyline for Fibromyalgia
Many things seem to come along for the ride when you have chronic pain, things like depression, anxiety, and fairly often trouble sleeping. It’s not uncommon for Amitriptyline to be given to people to help with their sleep, however, the actual evidence as to its effectiveness for helping with sleep is sadly very lacking. In fact, a few studies have looked at the effect Amitriptyline has day time sedation, finding that it was not uncommon in disrupting natural sleep and wake cycles. Anecdotally, we have worked with 100’s of clients before they came off the drug, and most would take their Amitriptyline 12hrs before they wanted to get up the next day, utilising the half-life of the drug to get around this.
Likewise, Amitriptyline is often used for tension headaches and migraines, which are very common in those with fibromyalgia. When it comes to migraines, surprise, surprise, we still aren’t entirely sure how they are caused as well. It is thought that low serotonin levels may contribute to the development of migraines in some individuals and that using amitriptyline, may help prevent them by increasing serotonin levels. However, this isn’t concrete. Tension headaches are thought to be caused by stress and muscle tension and typically don’t cause nausea, vomiting, or that sensitivity to light commonly associated with migraines. The leading theory as to the cause of tension headaches is believed to be muscle contractions in the neck and scalp, which can be triggered by stress and depression, head injuries, and even anxiety. Low doses of Amitriptyline, at around 10mg, are often prescribed for those with Fibromyalgia who suffer from tension headaches and migraines, with somewhat good results.
One of the main reasons Amitriptyline is prescribed to those with Fibromyalgia though, as you probably already guessed is pain related. One of the newer studies into Amitriptyline compared the effectiveness and safeness of two well-known antidepressants: Duloxetine and Amitriptyline. The researchers looked at eight systematic reviews of clinical trials and found that amitriptyline had fairly low evidence for effectiveness when it came to reducing pain, some moderate evidence for improving sleep and fatigue, and fairly high evidence for improving quality of life. Duloxetine, on the other hand, had high-quality evidence for its effectiveness in treating mood disorders. The study also found that duloxetine had higher acceptability, being safer for older patients, while amitriptyline was safer for non-elderly individuals. Overall, the study concluded that both drugs could be effective in the treatment of fibromyalgia for some, but the specific drug chosen may depend on the individual’s symptoms profile.
In addition to its partial effectiveness at reducing pain and potentially improving sleep, Amitriptyline could also perhaps have other benefits for those with fibromyalgia. For example, some studies have shown that Amitriptyline can improve mood and reduce symptoms of anxiety and depression. However, this could as easily be attributed to newfound wellness from not being in constant pain, as it could be related to the actual drug. Likewise, we know chronic pain stops people from sleeping properly, and with a lack of sleep, comes an increase in pain. It’s not a far reach to assume that those getting better sleep from the use of Amitriptyline would also see a reduction in pain.
Over the years, Amitriptyline has been used more and more off-label. This essentially means that the medicine is being used in a way that is different to that described in the licence for its use. Generally, some off-label uses of Amitriptyline include their use in:
- Generalised anxiety disorders
- Migraine prevention
Amitriptyline comes in three tablets of strength and also in liquid form: 10mg, 25mg, and 50mg.
The usual starting dose for adults and older children is often around 10mg a day, but you may find your doctor will ask you if you want to increase it if it isn’t doing much in the way of pain relief. The starting dose for younger children, however, really depends on their weight and symptoms. The maximum dose of amitriptyline for treating pain is 75mg a day in the Uk, but, you will likely find that this differs from country to country.
Whilst Amitriptyline is generally well-tolerated and has been around for a very long time, just like all medications, it can cause side effects in some people. Some of the more common side effects when using it can include drowsiness, dry mouth, constipation, and dizziness. These side effects are usually mild and may resolve on their own over time.
Other possible side effects of amitriptyline include:
- Blurred vision
- Changes in appetite or weight
- Changes in sexual function
- Changes in sleep patterns
- Dizziness or lightheadedness when standing up
- Drowsiness or tiredness
- Dry mouth
- Nausea or vomiting
- Urinary retention
In some rare cases, amitriptyline can actually cause more serious side effects.
- Allergic reactions, such as rash, hives, or difficulty breathing
- Chest pain
- Difficulty urinating
- Fast or irregular heartbeat
- Unusual bleeding or bruising
As with all drugs, everyone deals with side effects differently and the frequency and severity of them can vary a lot from person to person. It’s always a good idea to discuss the potential side effects of a medication with your doctor before starting any medication or making any changes.
Closing thoughts on Amitriptyline and Fibromyalgia
In summary, looking at the available research that there is for Amitriptyline and Fibromyalgia, there really isn’t a great deal of actual high-quality research backing its effectiveness when it comes to pain and Fibromyalgia. So, where does that leave us?
Well, it actually gives us a lot of food for thought around fibromyalgia, and indeed health in general. We know pain is frustratingly complex and caused by numerous factors all interacting together.
Why Amitriptyline may work for some and do nothing for others is most likely down to how complicated people are, rather than that actual drug itself. It’s akin to giving pain education to two people who suffer from headaches.
If person A believes that headaches cause damage, or they are afraid to move because they think it will cause more headaches, then pain education, could be effective at helping to reduce those headaches.
However, if person B, has, let’s say, an elongated styloid process which is impinging on a carotid artery, then it’s likely to not help at all. No amount of pain education is going to resolve that pain, it’s likely going to require surgery.
Why pain education may or may not work is down to three main factors: Biological factors, Psychological factors, and Social factors. I know that’s somewhat of an extreme example, but, it’s there to really get across the point that treatments for pain often don’t work because of complex factors that get overlooked.
Biological, Psychological, and Social factors are all intrinsically linked and you really can’t have one without the other two, it’s just how we are as Humans!
Biological factors can include: Inflammation, Arthritis, Sleep, Age, Genetics, Compression, and Mast cell responses to name but a few.
Psychological factors can include: Beliefs, Fear, Coping Skills, Trauma, and Anxiety to name but a few.
Social Factors can include: Friends and Family, Money, Global Pandemics, and your Environment to name a few.
So, when we look at Amitriptyline and Fibromyalgia, the reason that some may find it useful may not actually be anything to do with its proposed mechanisms for pain relief at all. But, more so to do with addressing underlying factors that increase pain in the first place.
As we mentioned before, sleep is incredibly important when it comes to pain, and sleep disturbances only add to increasing it. If Amitriptyline can help an individual to get better and more rested sleep, then it removes a major contributing pain factor: Sleep.
If someone’s pain is largely caused by another underlying factor such as compression, then its effectiveness is going to drop very quickly. Because Fibromyalgia is a syndrome, a collection of symptoms that commonly appear together, it means that there isn’t a catch-all fibromyalgia sufferer with an exact mechanism as the cause: pain is complicated because people are complicated. So, it means that when it comes to medications like Amitriptyline and its use for Fibromyalgia, their effectiveness is going to depend on the underlying factors as to why that person is in pain in the first place.
As we said before, there is a big jump in research needed when it comes to Amitriptyline and Fibromyalgia, hopefully, it isn’t too much of a wait to see it.
— The Fibro Guy Team —