Don’t let poor sleep ruin your life

Amitriptyline and sleep

The drug amitriptyline (also known as amitriptyline HCl or by the brand name Elavil in the USA) is one of a class of drugs that are not primarily sleeping tablets but can be used ‘off-label’ to treat insomnia.

Amitriptyline has been around since the 1960s and was originally developed to treat depression. While its popularity in treating depression has declined over the years, it has become increasingly prescribed for the treatment of insomnia.

This is because amitriptyline can have a sedative effect on those who take it. Traditional sleeping tablets come with the risk of developing tolerance or addiction so GPs often look to drugs like amitriptyline as safer alternatives.

Amitriptyline has multiple clinical uses.

In the UK, it’s licensed as an antidepressant and is prescribed to treat:

  • major depressive disorder (MDD)
  • nerve pain (neuralgia) and back pain
  • migraines and tension headaches.

(https://bnf.nice.org.uk/drug/amitriptyline-hydrochloride.html).

It’s used at higher doses for the treatment of depression and low mood (50mg- 200mg per day) and at lower doses to treat pain and prevent migraines (10-75mg per day). When used to treat insomnia, it’s given at low dose, typically within the range of 10-25mg per day.

backpain

Low doses of amitriptyline are commonly used for long periods in many people with chronic illness, particularly those with pain syndromes.1 This takes advantage of the fact that the drug has an effect on two chemical messengers, noradrenaline and serotonin, that are found in nerves and between nerve endings.

When you feel pain, these messengers relay signals to the brain that tells it that you’re in pain. When given to treat pain, amitriptyline blocks these two chemical messengers from relaying pain signals to the brain, so pain is reduced.

If you take amitriptyline at night to relieve pain, you may sleep better but that doesn’t mean that the drug is improving your sleep. It may be helping you get to sleep by reducing the pain that was keeping you awake but the drug itself is not, necessarily, having a direct effect on your sleep.

pain management

While we know that amitriptyline can be effective in the treatment of pain 2, its beneficial effects on sleep are much less clear. In fact, the drug may even have a negative effect on sleep, when taken for pain management.3

One treatment that is proven to be effective in treating insomnia for people with chronic pain is cognitive behavioural therapy for insomnia (CBTi).

This treatment has been shown to improve self-reported insomnia symptoms in people with chronic pain, with the improvement in sleep being maintained after the therapy itself has finished. 4 In this study, CBTi also reduced pain symptoms in about a third of the trial participants.

CBTi is the gold-standard approach for treating insomnia, and it’s what we use here at Sleepstation. So, if you’re experiencing insomnia associated with chronic pain, we may be able to help. Find out now, by taking our sleep quiz, to see how we can help you to improve your sleep.

Amitriptyline: the difference between sleep and sedation

Given that this drug is often prescribed by GPs for the treatment of insomnia, it may come as a surprise to learn that very few studies have actually looked at how amitriptyline affects sleep.

The theory behind its use is that as it can make you feel sleepy, it can help you to fall asleep and stay asleep. However, sedation and sleep induction are not the same things.

While sedation may play a role in helping you get to sleep, giving a feeling of restfulness or relaxation, drugs that cause sedation do not put you to sleep or keep you asleep.

Your sleep is controlled by two factors: your body clock and your sleep need. The need for sleep increases steadily over the course of the day. At the same time, your body clock is responsible for telling your brain when it’s time for you to sleep.

In normal, unmedicated sleep, by bedtime your sleep need is high and you’re ready to go to sleep. Your body clock sends chemical signals that tell your body to go to sleep, stay asleep and then, the next morning, wake again.

When sleep is achieved through sedation, this process is very different. Drugs like amitriptyline increase the concentrations of certain chemical signals in the brain and the result is that you feel sleepy quite rapidly after taking it and then hopefully stay asleep during the night.

Taking amitriptyline for sleep can affect your waking hours.

The drawback of this drug-induced sleep is that amitriptyline doesn’t just make you feel sleepy at night. It stays active in the body for 12-24 hours, so it can make you feel tired and groggy during the day too.

This effect of the drug has been extensively studied and it’s known that even at low doses amitriptyline causes daytime sedation and has a significant negative effect on daytime cognitive and psychomotor performance.5

This means that it can cause you to feel groggy or make you more clumsy which can affect your ability to carry out normal activities of daily living and can also impact your ability to drive.

clumsy coffee on computer

The side-effect of daytime sleepiness often leads the person to believe that they’re having problems sleeping. In fact, their daytime sleepiness is directly resulting from the drug they’re taking to help them sleep.

So it’s easy to see that this would be a big drawback to using amitriptyline as a sleep aid. This drug-induced sedation could actually result in a person being given more medications to help them with their assumed sleep problem when, in fact, they don’t actually have one.

Amitriptyline affects sleep quality.

In normal sleep, our bodies cycle through different sleep stages. We go through four sleep stages from light sleep to deep sleep and this repeats several times during each night.

When sleep is induced by amitriptyline, sleep stages are disrupted. As mentioned previously, amitriptyline is what is known as a tricyclic antidepressant and this category of drugs is known to suppress the deepest stage of our sleep: rapid eye movement (REM) sleep.

REM sleep is important as it is the stage in which the brain processes emotional information that we’ve experienced during the day. This stage is also thought to be when many types of memories are consolidated and laid down by our brains.

So for people taking amitriptyline this stage can be shortened. Emotional processing may be affected which can leave some users with feelings of anxiety and depression. This is why, when prescribed for insomnia, it’s very important to start with the lowest possible dosage.

Amitriptyline also reduces the amount of deep, slow-wave sleep (SWS), also referred to as ‘deep sleep’. During SWS our bodies are in housekeeping mode: our muscles repair themselves and new tissue is grown.

This type of sleep is therefore considered physically restorative but it’s also important for the consolidation of memories. Inadequate SWS sleep can leave you feeling fatigued in the short-term and can lead to serious illness in the long-term.

sleeping pills at bedtime

So can amitriptyline help you sleep?

Surprisingly, there is little, if any, evidence that amitriptyline can improve getting to sleep, staying asleep or any other aspects of sleep architecture relevant to disturbed sleep.6

Because of its effect on SWS, some researchers have expressed reservations about the use of amitriptyline to improve sleep, particularly for people experiencing chronic pain. For instance, Drewes et al., 3 stated:

“During amitriptyline and opioid treatment, a negative sleep profile may be induced, which can limit the use of these drugs in patients with pain.”

This is because both amitriptyline and opioid medications can cause a reduction in SWS and it’s been shown that a reduction in this deep, restorative sleep causes an increase in the perception of pain.7

There are no published studies on the efficacy of low-dose amitriptyline in insomnia either.1 Yet this drug remains highly prescribed by GPs as a safer alternative to traditional sleeping tablets.

Taking a prescribed sleep aid such as amitriptyline will not help to get to the root cause of a sleep disorder like insomnia. It will only mask the problem and can even make it worse.

This is where Sleepstation differs from medication treatment options for insomnia. Sleepstation is totally medication-free and requires only your ability to commit to following the programme. So with no wonder drugs involved, how do we succeed?

We use the gold-standard approach that’s proven to resolve all forms of insomnia ― cognitive behavioural therapy for insomnia (CBTi). Using CBTi, we’ll help you get to the root of your sleep problem and give you the guidance needed to improve your sleep for good.

You learn key sleep techniques and we provide you with the most up-to-date sleep science, equipping you with the tools to build a solid foundation for good sleep. We then help you to rebuild your sleep, step by step, brick by brick, to get you back to enjoying good-quality, restful sleep.

Our latest data shows that 84% of people using our service report recovery from their sleep problems after completing the course. So if you’re struggling with your sleep and want a clinically-validated, medication-free approach to overcoming your sleep problem, Sleepstation can help. Get started today.

In brief

  • Amitriptyline is widely prescribed as a sleep aid for people with insomnia.
  • There is a distinct lack of evidence that amitriptyline has any beneficial effect on sleep in insomnia.
  • It can cause daytime sleepiness and grogginess, which can interfere with daily life.
  • It can reduce the overall quality of sleep in those who take it.
  • It does not treat the root cause of the problem and so is not a good long-term treatment for insomnia.

References


  • Wilson S, Anderson K, Baldwin D, Dijk D-J, Espie A, Espie C, et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol. 2019;33(8):923–47.

  • Mercadante S, Arcuri E, Tirelli W, Villari P, Casuccio A.Amitriptyline in neuropathic cancer pain in patients on morphine therapy: a randomized placebo-controlled, double-blind crossover study. Tumori. 2002 May-Jun;88(3):239-42.

  • Watson CP, Chipman M, Reed K, Evans RJ, Birkett N. Amitriptyline versus maprotiline in postherpetic neuralgia: a randomized, double-blind, crossover trial. Pain. 1992 Jan;48(1):29-36.

  • Drewes AM, Arendt-Nielsen L. Pain and sleep in medical diseases: interactions and treatment possibilities (A review). Sleep Research Online. 2001;4(2):67-76.

  • McCrae CS, Williams J, Roditi D, Anderson R, Mundt JM, Miller MB, et al. Cognitive behavioral treatments for insomnia and pain in adults with comorbid chronic insomnia and fibromyalgia: clinical outcomes from the SPIN randomized controlled trial. Sleep [Internet]. 2019;42(3)

  • Srisurapanont M, Jarusuraisin N. Amitriptyline vs. lorazepam in the treatment of opiate-withdrawal insomnia: a randomized double-blind study. Acta Psychiatr Scand. 1998 Mar;97(3):233-5.

  • Holmberg G. Sedative effects of maprotiline and amitriptyline. Acta Psychiatr Scand. 1988 May;77(5):584-6.

  • Bye C, Clubley M, Peck AW. Drowsiness, impaired performance and tricyclic antidepressants drugs. Br J Clin Pharmacol. 1978 Aug;6(2):155-62.

  • Hindmarch, I., Harrison, C. and Shillingford, C.A., 1988. An investigation of the effects of lofepramine, nomifensine, amitriptyline and placebo on aspects of memory and psychomotor performance related to car driving. International clinical psychopharmacology, 3(2), pp.157-165

  • Raigrodski AJ, Christensen LV, Mohamed SE, Gardiner DM. The effect of four-week administration of amitriptyline on sleep bruxism. A double-blind crossover clinical study. Cranio. 2001 Jan;19(1):21-5.

  • Mertz H, Fass R, Kodner A, Yan-Go F, Fullerton S, Mayer EA. Effect of amitriptyline on symptoms, sleep, and visceral perception in patients with functional dyspepsia. Am J Gastroenterol. 1998 Feb;93(2):160-5.

  • Zitman FG, Linssen AC, Edelbroek PM, Stijnen T. Low dose amitriptyline in chronic pain: the gain is modest. Pain. 1990 Jul;42(1):35-42.

  • Onen SH, Alloui A, Gross A, Eschallier A, Dubray C. The effects of total sleep deprivation, selective sleep interruption and sleep recovery on pain tolerance thresholds in healthy subjects. Journal of sleep research. 2001 Mar 4;10(1):35-42.

  • Roehrs T, Roth T. Sleep and pain: interaction of two vital functions. InSeminars in neurology 2005 Mar (Vol. 25, No. 01, pp. 106-116). Copyright© 2005 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001, USA.