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Treating Migraines: Nortriptyline, Topiramate & Alternative Methods

Author Taylor Spurgeon-Hess covers Treating Migraines: Nortriptyline, Topiramate & Alternative Methods on BackTable ENT

Taylor Spurgeon-Hess • Jul 18, 2022 • 38 hits

Effective migraine treatment requires that the physician both pays attention to the patient’s lifestyle and diet, and has a solid understanding of the medications and their potential adverse effects. Apart from identifying and avoiding triggers, the first line treatment for migraines is nortriptyline. If that course of treatment fails, patients may turn to topiramate next. Alternative methods, like altering diet, may assist in symptom relief as well.

Dr. Djalilian, an otolaryngologist who focuses his research on migraines, shares his treatment tips. This article features excerpts from the BackTable ENT Podcast. We’ve provided the highlight reel in this article, and you can listen to the full podcast below.

The BackTable ENT Brief

• Nortriptyline functions well as a first line treatment for migraines; the only commonly seen side effects include somnolence and dry mouth, but on high doses QTC interval prolongation can occur so patients should first receive a clearing EKG.

• Topiramate may be added to the nortriptyline regimen or may be used as a stand-alone, second line medication in migraine patients who have an extensive cardiac history or a history of kidney stones.

• Major migraine triggers include stress, sleep, dehydration, hunger, and some food items.

• The typical food items that may trigger migraines include caffeine, tyramine in processed foods, glutamate in processed protein, and histamine in citrus fruits and nuts.

An otolarygologist explains treatment options for a patient with migrianes.

Table of Contents

(1) Prescribing Nortriptyline: Dosage, Side Effects, & Other Concerns

(2) Prescribing Topiramate: Dosage, Side Effects, & Other Concerns

(3) Alternative Methods for Migraine Treatment

Prescribing Nortriptyline: Dosage, Side Effects, & Other Concerns

While it is often not stressed during training in residency and fellowship, it is important to become increasingly comfortable with various migraine medications and their side effects. Many otolaryngologists turn to nortriptyline as the first line medication for migraine treatment. Dosage varies based on whether or not the patient experiences frequent vertigo, but for patients without vertigo the dose starts at 10 mg and increases by 10 mg every two weeks until the dose reaches 75 mg. For the patients who do experience frequent vertigo, dosing may begin at a higher level, such as 25 mg, and may increase to 50 mg after only two weeks.

While the list of potential side effects is long, many patients only experience common side effects such as somnolence and/or dry mouth. If symptoms persist after the dose hits 75 mg, and the physician increases the dose further, they will likely order an EKG, as nortriptyline may cause a prolonged QTC interval. If a patient takes a variety of other serotonergic medications, they may not be a good candidate for nortriptyline, but proper monitoring can minimize the risk of experiencing serotonin syndrome. Patients sensitive to medication can start on liquid nortriptyline at pediatric doses of 2 or 5 mg.

[Walter Kutz MD]
So nortriptyline, 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.

Listen to the Full Podcast

Otologic Manifestations of Migraine with Dr. Hamid Djalilian on the BackTable ENT Podcast)
Ep 60 Otologic Manifestations of Migraine with Dr. Hamid Djalilian
00:00 / 01:04

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Prescribing Topiramate: Dosage, Side Effects, & Other Concerns

In patients with a history of arrhythmias or an extensive cardiac history, nortriptyline should be avoided, and topiramate functions as a great alternative in these cases. Side effects are uncommon at low doses, but patients may experience paresthesias on their fingers or around their lips. As a carbonic anhydrase inhibitor, it acidifies the urine, so it should be avoided in patients with a history of kidney stones.

Topiramate’s dose regimen spans six weeks; patients begin at a 25 mg dose which increases by 25 mg each week, up to 150 mg. The six week timeline allows the otolaryngologist to check in on the patient’s progress and assess their responsiveness to treatment. While in some cases topiramate stands alone, often, it is added to nortriptyline if a patient is already taking that without seeing full symptom relief.

[Walter Kutz MD]
Actually, I'm going to ask you about topiramate. I know that's a second line treatment. What are the side effects of topiramate that you're concerned about? It sounds like you feel it’s very safe medication for most patients, but what kind of side effects do you discuss with patients?

[Hamid Djalilian MD]
The main side effect that people can get from topiramate at the low dose, I should say at low doses, it’s very uncommon that people get side effects, but if they do get side effects, it will be sometimes they'll get paresthesias around their lips or their hands, their fingers. It is a carbonic anhydrase inhibitor so it sort of has that effect, like acetazolamide does, and then very uncommonly patients can have kidney stones from it, because it acidifies the urine. So I tell them that if they have kidney stone history, then I don't give it. Or sometimes I'll say, if that's the only thing left, I'll tell them, go check with your urologist to make sure you can take this because there are some stones. If their stone has been identified, acidification is not an issue for it.

[Walter Kutz MD]
What's your typical dose regimen for topiramate?

[Hamid Djalilian MD]
Yeah, topiramate I start it at 25, and go up once a week, by 25 milligrams, up to 150. So it's a six-week regimen. Most of the dosage regimens I have are six week regimens. So I start the patient. It's not too long so that they don't feel like I'm abandoning them by telling them to come back three months later. And then at the same time, I want to be able to have control over it, so that if anything is not working, then we can make adjustments quickly for them so that they don't suffer for too long. So I usually will start them on whatever medicine we're going to start, and see them usually in six weeks. And then, based on what their symptoms are at that point, then we'll make changes to their regimen.

[Walter Kutz MD]
I think we've spoken about this before, if nortriptyline is not working a lot of times, you'll add topiramate to that. Is that true?

[Hamid Djalilian MD]
Exactly. Yeah. So, there is an additive effect that we see with the medications. So I will combine them, once they are better, then I'll slowly take away the first drug that didn't work as well. And then I generally try to, I tell the patients, this is for three months, you're going to be three months of stable symptoms, meaning no symptoms, or if you have a symptom you can easily identify the trigger. So they say, well, I didn't get good sleep this night, and then I got dizzy the next morning. And so then I know, well, it's a sleep problem. I'm not going to raise their dose or keep them on medication forever because they know what their trigger is. They just need to fix that problem basically. So I will usually keep them for three months on the combo. We'll start taking away the first drug and then we'll then take away the second drug. And then at the end, we'll tell them to start experimenting with the food items so they can find which food items they're triggered by. And then if everything goes well, they've identified their triggers, they can avoid them. And then there'll be good. I mean, I tell them, I have migraines, I know what my triggers are. I'm very careful with them. And so then I don't get symptoms. I don't have to be on daily medication. I don't have to do anything. I just know what I need to do to make sure I don't get it. And so then I'm very careful and that's what you need to do. That's what I tell the patients.

Alternative Methods for Migraine Treatment

While medications can help to reduce symptoms and provide increased comfort to patients, the best method for preventing migraine symptoms involves identifying and avoiding triggers. Major triggers include stress, sleep, dehydration, hunger and certain food items. Specifically, triggering food items include caffeine, tyramine in processed foods, glutamate in processed protein, and histamine in citrus fruits and nuts. These triggers often cause a migraine within six to eight hours. Other resources such as articles, handouts, and books are also helpful; Dr. Djalilian recommends the book Heal Your Headache to his patients.

[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.



[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.

Podcast Contributors

Dr. Hamid Djalilian discusses Otologic Manifestations of Migraine on the BackTable 60 Podcast

Dr. Hamid Djalilian

Dr. Hamid Djalilian is the director of Otology, Neurotology, and Skull Base Surgery at UC Irvine in California.

Dr. Joe Walter Kutz discusses Otologic Manifestations of Migraine on the BackTable 60 Podcast

Dr. Joe Walter Kutz

Dr. Joe Walter Kutz is a neurotologist and Professor of Otolaryngology and Neurosurgery at the University of Texas Southwestern Medical Center in Dallas, TX.

Cite This Podcast

BackTable, LLC (Producer). (2022, May 24). Ep. 60 – Otologic Manifestations of Migraine [Audio podcast]. Retrieved from https://www.backtable.com

Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.

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