Nortriptyline & Topiramate For Migraines

[Walter Kutz MD]
So nortriptyline for migraine treatment, that's kind of my first line as well. I think one thing we have to get comfortable with, if we're going to treat patients with migraines, is the medications. And that's really not in our training or at least not in my training back in my residency and fellowship. So I think nortriptyline, it sounds like it's a good first line. I think it sounds like most otolaryngologists can get pretty comfortable treating that. Can you tell me a little bit about your dosage and side effects and concerns with nortriptyline and how you discuss this with a patient?

[Hamid Djalilian MD]
So I start with, usually depending on the patient, if someone is getting very frequent vertigo, and just wants to get better, like ASAP, I will start them at 25 milligrams. And then usually go for two weeks and then increase it to 50. And then if they're not better after two weeks of that, then we'll go to 75. But most patients, we're not getting very frequent vertigo. I will start them at 10 milligrams and then every two weeks will increase by 10. So we go 10, 20, 30, and then from 30, we'll usually jump to 50 and then 75, that's sort of the routine.

The main side effects, I tell the patients, usually, don't panic when you see the side effect list on the package, insert that the pharmacy will give you. I sometimes tell them, don't look it up, because nortriptyline was FDA approved for depression at very high doses. We never reach those doses that nortriptyline was used for. So we rarely see those uncommon side effects that are listed on the package insert. The side effects that we do see is somnolence. So most people will get sleepy from it. And I think that's one of the potential reasons nortriptyline, in addition to probably its anti-migraine activity, it helps because it makes people sleep better and sleep is a very significant trigger for patients with migraine. The second is at low doses and nortriptyline has an anti-anxiety effect. And so it does help with the stress component of migraine, which is another significant trigger. Stress and sleep are probably the most common triggers. So it sort of controls two of the triggers in a way, plus it helps them with the migraine at the same time. And then, I tell them about somnolence. I tell them about dry mouth. Some people get dry mouth at low doses, but generally speaking, it's not a big problem, I must say. People can get tachycardia from it. I tell them to check their heart rates before they go up on the dose, make sure that it's less than a hundred, their heart rate. If we're going to maintain them at 75 or raise the dose potentially, sometimes people have gotten better, but they're not fully better. So they're at 75. And so then I want to push it up to like 85 or maybe a hundred sometimes. I will then get an EKG to check for the QT interval or the QTC technically, and to make sure that that's not increased, because rarely of course, nortriptyline is associated with increased QTC interval. And so we just have to keep that in mind if we're going to keep them on it long-term. I don't check blood levels like was traditionally done in psychiatry. I just go based on the EKG.

[Walter Kutz MD]
One of the challenges of nortriptyline is if I have a patient, either with vestibular migraines or Meniere’s disease I want to treat as a migraine variant, they may be on other medications, psychiatric medications, other migraine medications, or maybe it's a patient that's an older patient. I worry about putting these patients on these sort of medications, you know, again, being an otolaryngologist, not a neurologist. How do you address the patients that are on medications for migraines or maybe psychiatric medications, anxiolytics. And also, secondly, are you comfortable prescribing nortriptyline for older patients?

[Hamid Djalilian MD]
Yeah, great question. So I usually will do nortriptyline if there, I used to actually not do it at all, if they're on another serotonin blocker of some kind, an SSRI or SNRI. Over time I have become a little more brave, I should say. As long as they're not on like four times the dose, I had a patient, who is a psychiatrist himself. He was on like two or three antidepressants and he had sudden hearing loss and I treat sudden hearing loss as a migraine phenomenon. And so I give them nortriptyline and I told them, serotonin syndrome. He said, we never worry about serotonin syndrome. I said, well, just keep track of your heart rate and all that. And, I tell patients if they're on it, other antidepressants at high doses, usually four times the starting dose. So for example, for Zoloft, if they're on 200 milligrams or something, I'll tell them, if your heart rate goes up, you feel the sweating and things like that go to the ER and say, I'm on these medicines and they will know what to do. So that's what I usually tell them. I must say I haven't had any, I do give it to elderly patients.

Some patients are very sensitive, so migraine patients are very sensitive to medications. So sometimes I will start them using the liquid nortriptyline, which is for pediatric usage. So I'll give them like five milligrams or sometimes even two milligrams. And so I have given it in elderly. There is a warning that comes up on the electronic record system about over 65 and the problems with anticholinergics and things like that. I must say I have not had that problem. People generally start feeling well at some point, it's uncommon in the elderly. We have to go up really high on the dosage. I do use paroxetine or Paxil as an alternative to nortriptyline if there's any question of arrhythmia. So if the patient has an arrhythmia history, I don't want to risk it. So I will not use nortriptyline in those cases, I'll use paroxetine or topiramate. So topiramate is a very good medicine or Topamax. If someone has an extensive cardiac history and you're worried about messing up their blood pressure or heart rate or rhythm then topiramate is something that's totally foolproof for that kind of problem.

[Hamid Djalilian MD]
So, just sort of for the listeners, I lay out the five main triggers, which are stress, sleep, diet, and I tell them the diet is dehydration, hunger, and then the food items. And the food items are primarily caffeine, glutamate, which is in preservative, so ready to be packaged foods, basically, things like that, tyramine, which is in protein that's been processed in any way, or protein that sits around a long time basically. It could be dried fruit. It could be a very soft fruit, things like that. Bananas are very high in tyramine. The fourth molecule would be histamine and that's in citrus fruits and in nuts. So I tell them about those. I have a handout that was actually originally developed by John Carey and Michael Teixido, and I made a lot of edits to it. I've changed the diet a little bit, based on sort of my own experience in reading, and added a number of other conditions. And I tried to make it a little bit more understandable for the patients. So I give them that handout. If there are patients who really want to drill down, I do have this like, it's like a grocery list, that I initially got online. And then I made a lot of changes to it. And then I will recommend they read the Heal Your Headache book, by the author, his name is Buchholz. And that has a very comprehensive diet chapter. And so I tell them to follow everything that's in that book.

[Walter Kutz MD]
One of the challenges I've run into is you may recommend reading a book and reading these handouts and it may be a patient that you just sense is not going to really do the sleep hygiene, dietary changes. And as a patient, I'm probably guilty of this as well. But, is there anything you do, if you have a patient, they come in and they say, no, doc, I just want you to give me medicine to get better. What do you say to them?

[Hamid Djalilian MD]
I usually tell them there are two parts of this deal. There is the part that I'm going to do, and there is a more important part that you have to do. And I say, if you don't fix your trigger, there’s no amount of medicine that can overcome some of these triggers. So if someone is consuming six, seven caffeinated beverages a day. If someone has obstructive sleep apnea, if they have chronic insomnia, I tell them we have to fix that as part of fixing this. I basically described to them that there's a threshold in the brain and when the brain activity reaches the threshold, then they will start getting symptoms. And, there are two approaches to this, one is to elevate the threshold so that they don't get symptoms. And that would be with medications. And the other would be to reduce the activity, which would be the trigger control. And I say, you have to do two together because the patients want the easy way out. And that's totally understandable. That's what I would want to do potentially, but I tell them this is a more natural way of doing it. You have to live with this condition forever. You might as well identify what's causing the problem and control that. Because especially in younger patients, I tell them, I'm not going to put you on medication forever. You need to learn what your triggers are, so you can manage this problem. So I really do try to spend time.

Now, I definitely agree that not every patient is compliant and definitely the average migraine patient has obviously more anxiety and stuff because that's a significant trigger for a lot of them. And so, they're not always easy to convince, but, I usually, when I see them sometimes initially, or, most times initially I see them with my PA or I see them on my own, and then they will follow up with my PA or nurse practitioner and then they will see them, and if they're not getting better than those sort of come back in and I’ll talk to them. And by the end I usually go and kind of lay down the law. I said, listen, you need to follow this stuff. Otherwise we're not going to even give you medications anymore because if you're not controlling that, we can't control the condition and then you're going to blame me, but it's really a problem that you need to be working on. And so I do have patients, if they're not getting better and they say, none of this stuff, you gave me work. And so I tell them, you're going to have to write down everything you ate, how much water you drank, how much sleep you got, all that stuff and bring that to me. And so then we can identify stuff for them because a lot of times, I've had a patient who was an engineer and he had this giant Excel sheet he brought in and he said, there is no pattern to any of this. And I said, just let me look at it. And it was very clear to me, every morning that he had a ham and eggs breakfast, he got dizzy that same day. But it was like six hours later, of course. And so, because the patients are looking for something that happens immediately, and I said, this is your pattern. And that's all he had to do. We fixed that problem altering his diet. There was no medication needed. So a lot of times it takes a little time. I've educated a few PAs and NPs, who work with me, who really spend the time because the patients do need a lot of time sometimes. And I just don't have the time to do this with everyone. And so I need to rely on physician extenders to help me, so that we can help more people.

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[Walter Kutz MD]
So, how do you tell them to log their symptoms? Is this something that you just leave it up to them? Are there suggestions like an app or do you tell them to journal? How do you tell them to log their symptoms?

[Hamid Djalilian MD]
Yeah. I have this little form that we created basically has like what their symptoms warrant, what time that was, what they ate that day. I usually tell them the trigger is generally within about six to eight hours of the episode. So I tell them if it's like three in the afternoon, look very specifically at what you ate at lunch, and how much water you had to drink and whether you ate enough and you're not hungry, whether you had stress. I usually tell them that if their sleep is inadequate or the sleep trigger, most commonly, they're going to wake up with the symptoms. So patients who wake up in the morning, it's usually most commonly going to be sleep, but it can be due to a food item they ate at dinner, for example, dehydration or hunger and not eating enough at dinner. And then, very critical early morning one is caffeine withdrawal. So I tell patients to completely eliminate caffeine slowly over a couple of weeks because caffeine withdrawal is a significant trigger for migraine.