A simple guide to amitriptyline for nerve pain

In this article:

• What is nerve pain?
• How does amitriptyline work?
• Timeline for relief
• Dosage
• Side effects
• Contraindications and interactions
• Alternatives
• Living with nerve pain
• The bottom line

In this article

• What is nerve pain?
• How does amitriptyline work?
• Timeline for relief
• Dosage
• Side effects
• Contraindications and interactions
• Alternatives
• Living with nerve pain
• The bottom line

Nerve pain can be a long-term, frustrating condition that interferes with daily life. For many people, amitriptyline offers relief, even though it wasn’t originally designed for pain.

Amitriptyline is a generic antidepressant that’s FDA approved to treat depression, but is often prescribed off-label for several conditions, including anxiety, irritable bowel syndrome, post-traumatic stress disorder, insomnia, migraines, fibromyalgia, and nerve pain. It can help reduce the constant burning, tingling, or shooting sensations that come with nerve-related pain by changing how your body processes pain signals.

If you’ve been prescribed amitriptyline for nerve pain, you might wonder how it works, how effective it is, and how long it takes to feel a difference. This guide answers those questions and explains what to expect along the way.

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What is neuropathic pain?

Neuropathic pain, or nerve pain, happens when the nerves that send signals to your brain malfunction. It is “pain that is not due to damage or injury directly, but is caused by a problem with nerves themselves that pass along sensory information,” says Noah Rosen, MD, a neurologist and director of headache medicine at Northwell Health.

This miscommunication can originate anywhere in the nervous system. “This can be either in the brain, spinal cord, or peripheral nerves,” explains Meera Nair, MD, attending psychiatrist at the department of behavioral health at Saint Anthony Hospital in Chicago. “It can feel like burning, tingling, or an electric-shock type of pain.”

Neuropathic pain is different from nociceptive pain, which comes from disease or damage to non-nerve tissues like your joints, skin, or muscles. “The kind of pain you feel from arthritis, or a sprain or strain, is more of a dull aching type of pain,” Dr. Nair explains. “Unlike ordinary pain from injury or inflammation, neuropathic pain can linger even after healing is complete, and it generally doesn’t respond well to typical anti-inflammatories.”

Nociceptive pain typically resolves within days or weeks. Because nerves heal much more slowly than other tissues, neuropathic pain tends to last longer. Nerve pain “has very poor healing potential and heals on a time course of months if at all,” says Alexander Leos, DPM, a foot and ankle surgeon in New Orleans, Louisiana. As a result, nerve pain is more likely to become a chronic condition.

How does amitriptyline work for nerve pain? 

Amitriptyline is a tricyclic antidepressant (TCA) originally approved by the FDA to treat depression. However, it’s also considered first-line treatment for nerve pain, and healthcare professionals frequently prescribe it off-label for this purpose. It’s sometimes used for other chronic pain-related conditions, such as migraine, fibromyalgia, irritable bowel syndrome, and post-COVID headaches.

Amitriptyline helps reduce nerve pain in two main ways. First, it boosts levels of serotonin and norepinephrine in the spinal cord, chemicals that help regulate how pain messages are processed. This helps dampen pain transmission. Second, amitriptyline “stabilizes nerve activity by acting on sodium channels and NMDA receptors,” which can reduce the misfiring of pain signals in the nervous system, says Dr. Nair. 

Because of these effects, amitriptyline can help lessen the intensity and frequency of chronic nerve pain. Still, it doesn’t work for everyone. Research suggests that about 25% to nearly 40% of people taking amitriptyline experience meaningful pain relief, compared to roughly 15% taking a placebo.

How long does amitriptyline take to work for nerve pain?

Amitriptyline doesn’t provide quick pain relief like typical painkillers because it works differently. It gradually changes how your nervous system processes pain signals. Most research shows that it can take six to eight weeks to feel the full effects for nerve pain.

Some may notice pain reduction sooner. “Like a lot of other antidepressant medications, patience is key,” Dr. Nair says. “It takes 2-4 weeks to feel some level of meaningful change.” Taking the medication consistently and giving it time to build up in your system is essential for your results.

Amitriptyline dosage for nerve pain

The typical amitriptyline dose for nerve pain ranges from 10 to 150 milligrams (mg) per day, usually taken at night. It’s typically lower than standard doses used to treat depression. Most of the time, your provider will start you on a low dose and gradually increase until you reach the most pain relief with the fewest side effects.

“We start at 10 mg to 25 mg nightly and increase to 50 mg to 75 mg,” Dr. Nair says. “It makes people drowsy, so we dose it at bedtime.” Dr. Leos takes a similar approach. “25 mg/day is my most common starting dose as most patients will feel some effect, good or bad, at this dose,” he says. “The dose can be adjusted upward regularly until either nerve symptoms are controlled or side effects limit the dosage.”

Whatever dose you are prescribed, consistency is key. Take it as directed, avoid missed doses, and stay in touch with your healthcare team about how the medicine is affecting you.

Potential side effects

The most common possible side effects of amitriptyline include:

• Dry mouth
• Constipation
• Urinary retention
• Orthostatic hypotension, which is when blood pressure drops suddenly when you stand up

Rarely, more serious side effects occur, such as:

• Racing or irregular heartbeat
• Trouble breathing
• Chest pain
• Seizures
• Atypical bleeding or bruising
• Blurred vision
• Allergic reactions
• Restlessness, anxiety, hallucinations
• Self-harming thoughts or behaviors

If you or a loved one is experiencing any of these serious side effects, it’s vital that you seek immediate medical attention.

Who should avoid amitriptyline?

Amitriptyline can sometimes make you drowsy and can have concerning impacts on older individuals. “Care should be taken in older adults as amitriptyline has a strong sedative effect and can increase the risk of falls,” Dr. Leos advises.

Other common side effects of amitriptyline, like dry mouth, dry eyes, and constipation, should also be considered. If you are already dealing with any of these issues, try a different medication. In addition, amitriptyline is not a good option for anyone with arrhythmias, glaucoma, or urinary retention.

Because amitriptyline can impact the levels of serotonin in your body, you should exercise caution if you are taking other drugs that increase levels of serotonin in your body. “Care should be taken in patients who are already on other medications that modulate serotonin due to a potentially life-threatening condition called serotonin syndrome,” Dr. Leos recommends.

Amitriptyline alternatives

While amitriptyline can be a helpful drug for some people with nerve pain, it doesn’t work for everyone. Not only that, but it should be avoided in certain people, such as older adults, people with medical conditions like glaucoma and arrhythmias, and people who are taking other serotonin-enhancing drugs. 

According to Dr. Nair, amitriptyline alternatives to consider include:

• Cymbalta (duloxetine)
• Lyrica (pregabalin)
• Neurontin (gabapentin)
• Effexor (venlafaxine)

“Nerve pain is a challenging condition and medication is just one part of the plan,” adds Dr. Nair. For the best results, medication should be paired with complementary non-pharmacological approaches like:

• Getting physical therapy
• Engaging in gentle movement and exercise
• Practicing good sleep hygiene
• Using relaxation and breathing techniques
• Limiting alcohol
• Avoiding smoking
• Keeping your blood sugar stable if you have diabetic neuropathy

Living with neuropathic pain

Neuropathic pain can be a difficult condition to live with and affect quality of life. “Neuropathic pain is generally chronic and for most patients is not realistically curable,” Dr. Leos says. But there’s hope. “Most patients can reach a tolerable level of symptoms with appropriate care,” he says. This care may include medications like amitriptyline, and also interventions like psychotherapy, physical therapy, pain education, and in some cases, surgery.

It’s important to take a holistic approach when managing neuropathic pain and take into account some contributing factors. “The contribution of anxiety, depression, poor sleep, and other psychological factors in predisposing people to chronic neuropathic pain and amplifying chronic neuropathic pain should not be overlooked,” Dr. Leos notes.

Bottom line: Is amitriptyline right for your nerve pain?

While amitriptyline doesn’t work for everyone with nerve pain, it’s considered a first-line treatment. It’s usually most effective when combined with other therapeutic approaches like physical therapy, relaxation and breathing techniques, exercise, and psychotherapy. Your healthcare provider can develop a treatment plan based on your medical background and health needs.