Update: Dr Silver medications

Hi everyone

I thought I would post an update now Dr Silver’s letter has arrived following my appointment with him a few weeks ago. Some people wanted to know the meds he recommended and the titration schedule so here it is HOWEVER I must stress this is his recommendation for me alone and I know he has different recommendations for different patients:

Firstly my diagnosis is: Migraine vertigo
With regard to Nortriptyline he says to stay at 20mg as ‘I don’t think there is scope to increase this further’ - I am not sure why?
Tighten up lifestyle a little by eliminating caffeine (chocolate for me) and painkillers.
Blood test for full blood count, B12, folate, thyroid function, calcium, electrolytes, liver function, iron binding, ferritin and blood sugar.
Gabapentin to help sleep quality at night - 300mg at night increasing if necessary to 600mg after 2 weeks. Scope to go to 900mg if well tolerated and providing partial benefit to overall state.

Migraine Preventatives:

First line - Metoprolol at 50mg once a day, increasing by 50mg every 2 weeks anywhere up to 100mg twice a day.
Second line - Topiramate at 25mg at night, increasing every 2 weeks in twice daily dosage by 25mg. Maintenance dose of 50mg twice daily but scope to increase to a maximum of 250mg twice daily if tolerated and helping.
Third line - Sodium valproate (Epilim Chrono) initial dose 200mg at night and increased by 200mg each week in twice daily dosage up to 400 and 800mg twice a day. Scope for 1000mg twice a day if necessary.
Fourth line - Flunarizine off licence therapy. Start at 5mg at night increase to 10mg after a few weeks if the lower dose is tolerated but not helping. 15mg may be considered if tolerated.
Fifth line - Zonisamide at 25mg at night increased to 25mg twice daily after a week. The dose can increase each week by 25mg to an initial dose of 50mg twice daily and if well tolerated can increase by 25mg a week to a dose that is tolerated. The maximum dose is 200mg twice daily.

There is a warning for all these drugs, except the Metoprolol, about the potential harm to an unborn foetus and the need for birth control and for Topiramate the fact it may weaken the oral contraceptive for women is stated.
There is also a warning that if any of the drugs cause any problems whatsoever with memory, mood or speech then they must be stopped immediately as they will not help the disorder.

Also enclosed with my letter is an information bulletin on headache and chronic pain - it is much the same as the audio talk we have on this site from Dr Silver. However I did note that he says in this information bulletin re migraine preventatives that 'The commonest drugs include beta blockers (propanolol or atenolol), the tricyclic antidepressants (eg amitriptyline, dosulepin) or the anticonvulsants (eg sodium valproate, topiramte). Older drugs such as pizotifen are poorly tolerated and drugs such as carbamazepine or clonidine are generally ineffective."

It surprised me about pizotifen as I have read many success stories with that and many people said it was easily tolerated. The main reported side effect seems to be weight gain!

One final thing, he says if a preventative is successful it should ideally by used for 1 year at the dose reached and then slowly withdrawn over 3 to 4 months. The preventatives typically take up to 3-4 months AFTER reaching the maximum or maximum tolerated dose to start taking useful effect at turning off migraine. So give them a good trial before stopping unless the side effects are intolerable.

I hope this info is useful to others and if anyone wants to ask me anything feel free x

Thanks Jem, have I read this correctly that you will stay on the nori at 20mg’s and then add the ‘meto’ firstly and see how it works for you? Fingers crossed of course that it does work out but at least you have a plan x

Yes that’s right Anna, to stay on Nori at 20mg and add Metoprolol as the first line preventative. Really hoping it works out as the others in the list sound quite scary! x

He uses different meds to Dr S totally I think? Pitzotifen has helped lots that I know of about five people in total I so hope this works out for Jem but Ive never heard anyone get well on Metoprolol is this a new med ? what class is it in?

Im getting results of amitriptyline now the only other meds I would go on at this point is topamax or pitzotifen. I know gabentin can work well but Im questioning how you will know which drugs are working for you when your on three is this a concern of yours too? Dr S goes up to 75mg on nori before he would consider it a failure it seems Dr Silver is taking an all guns blazing approach with you and I hope it pays off because you deserve it so much x

Well done jem. Glad you got the meds. Dr silver knows his stuff i would trust him and give it a go x

Metoprolol is a beta blocker, I think its like propanalol and I have heard of some successes with that. I am ok with taking it and seeing what happens. The others down the list scare me a bit. I might take the metoprolol for a few weeks first before adding the gabapentin as I want to see what each one does. Yes it does seem like an all guns blazing approach - I am desperate now so happy to try anything. I will keep everyone posted anyway.

Thanks for your help Rob x

Yes Jem I think a no fear attitude with meds is the way to go! You will beat this x

Thanks Donna, I really hope we all can beat it x

I just found this link to studies on the efficacy of many of the migraine meds which might be interesting reading for anyone considering what to try next:


Great report Jem! S 8)

Good luck with all your meds Jem. Hope you have some great success!
Anne x

Thanks soo much for your post! I found it extremely helpful and I sure hope the meds Work for you! Its interesting how Dr S says to bid up to 250 mg with the topa…i was wondering if 100 mg was the limit. Please keep us updated on ur progress!!


Jem, thanks for posting such an informative report of your visit to Dr Silver. It’s great that he has forwarded such a clear plan for you and your GP to follow! I do wish my specialist had done the same - it has taken me a year to get to a med combo which is working for me. I’m sure I would have felt more hopeful if I’d had all the options laid out initially. Maybe I should have asked for one!
As you say, this is tailored just for you - so many factors to take into account when drugs are prescribed. Good luck!

Thanks for your comments, so glad you found it helpful. I am feeling reassured that I have had a thorough plan from Dr Silver and others agree. I just phoned my GP about the meds and was told the prescriptions were already awaiting my collection! Wonders will never cease! x

Good luck keep us posted :smiley:

Its encougaging to know his time frame of 3-4 months for the med to work, I had better hang on with Topamax for the long haul, Ive only been on 100mg for 1 week!

Jem I’d say 2 weeks isn’t long enough to see if metoprolol is working before adding gabapentin - just my 2c (I take it)


Thanks for that. I will wait longer then. I have only been on the Met for one day but today I feel tired. Wondered if you could tell me all the side effects you had and if you have any now?

I am so glad it has helped you x

Hi Jem,

I am on pizotifen and it was making me tired but the last couple of days i have felt ok. Some side effects can wear off after time

Hi Rob, yes that’s what I am hoping. I feel very drowsy but maybe I will have a smaller dose today and work up a bit slower x

Hi Jemma,
I was tired and a bit fuzzy on and off for the first couple of weeks on Metoprolol. It did start to wear off though and if it works for you its worth a few days of tiredness. Hope it does.