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.
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