Otologic Manifestations of Migraine

[Hamid Djalilian MD]
Yes. I think a lot of literature is on venlafaxine or Effexor. I don't use it very commonly. Sometimes the patient will come in insisting that they want that. And so I will give it to them, but generally speaking, I will start with just the routine nortriptyline, topiramate. I mean, when you think about really nortriptyline, I mean, it is a tricyclic antidepressant, but its effect is like an SSRI/SNRI, which is what venlafaxine is. And so I usually just start with what I use most commonly and I know the side effect profile. I know all of the intricacies of it. I think it's good to become familiar with the sort of meds, which probably more than 95% of patients are going to be on one of three medications, which is nortriptyline, topiramate, or verapamil.

I will use paroxetine as well, probably in those that I think have a lot of the stress component or sleep component, but they can't take a TCA because of cardiac related issues. So, those are probably my go-to meds. I do use venlafaxine, but probably much less commonly. I think the etiology, at least based on the patient's history and our papers that are going to be coming out hopefully soon, are that these are migraine related problems. That PPPD is a migraine related issue and it really treating the migraine helps them. I think a lot of times when studies are done, they are done because you try to control it. So you say this person gets this medicine at this dose and this group just gets a single pill. And the problem with migraine, it's a lot more complex than that. You need to sort of do the lifestyle changes and you need to do dose escalation, which very few migraine trials do, or PPPD trials I’d say. So, I don't subscribe to the one pill, one dose regimen of treatment, because I think everyone's different and people's sensitivity and tolerance is different and all that stuff. So, so I try to tell patients, it's not very simple like I can just give you a single pill and that's going to fix it. It might take two or three pills. It might take a couple of months to get to these doses. You need to do the lifestyle change. But if we do all this stuff, I can tell you with high degree of certainty, you will get better. And sometimes I should say that it's really important that we communicate to the patient, that we know what you have, and we know we can get you better. And that a lot of times has a pretty significant, positive psychological impact on the patient because they've seen several physicians and they've told them, I don't know what you have or, there's nothing else I can do for you. And so then there's this sort of despair, and stress and depression that comes from that. And I think, giving them the confidence really, I think helps sort of turn the page on and trying to get them better.