Migraine Management for Otolaryngologists: Advanced Migraine Management Pearls

If patients describe their dizzy symptoms as: bouncy, spacey, rocking, falling, floating, displaced in space, walking on foam:

• This is a central response from the thalamus
• These symptoms cannot be caused by the inner ear
• Confirmatory of central dizziness
• These patients will tell you that meclizine had no effect on their symptoms

• Many of these patients have symptoms that resolve when lying down
• Symptoms may be worst in initial rising but persist while upright
• If possible vascular origin of dizziness(hypoperfusion), consider Fludrocortisone 0.1mg: start 3 times per week if there is a hypertension concern , otherwise 0.1mg daily
• Have patient self-monitor BP in same arm, position, time of day to get a baseline and then during treatment

• Beers List: Anticholinergic drugs with potential to increase dementia risk(over 200 meds)
• Nortriptyline 75mg x 3+ years: patient is at increased risk of dementia
• Start 10mg nightly and escalate by 10mg weekly
• Often good response at 20-30mg
• Because nortriptyline is a capsule it cannot be cut. It has a long half-life though(72hours) so a dose of 15 mg, for example, can be obtained by alternating 20mg, 10mg 20mg etc.
• Common side effects: dry mouth, drowsiness, weight gain long term
• If lower than 10 mg needed consider amitriptyline 10mg tab that can be cut
• Weight gain is often associated with cravings for carbohydrates and increased caloric intake. Portion control can manage this. Others suffer weight gain because of changes in metabolism.

• Slow dose escalation minimizes side effects
• Start 25mg daily x 1 week, then bid, then increase weekly to 50mg bid (can go up to 100mg bid)
• If symptoms disappear stop titrating up
• If side effects limiting can use tid dosing to prevent high serum levels

• If patient is already on metoprolol and having vestibular/migraine symptoms, switch them to propranolol at a similar dose. This is often successful because propranolol has better central penetration.
• Reassure patients that if they don’t have elevated BP, starting a BP medication for migraine will generally not make them hypotensive
• Use with caution in asthma or diabetes
• Starting dose (LA): 60mg/d – increase PRN to 180mg/d
• Nortriptyline and propranolol work well together
• Propranolol is a good initial choice when anxiety is a driving factor for migraine symptoms. Propranolol is a mood stabilizer and prevents reaction to adrenaline.

• Hemiplegic migraines respond uniquely well to calcium channel blockers (verapamil, diltiazem)
• There is a general misconception and misteaching that CCBs don’t work for migraine and many chronic migraine sufferers who think they have tried everything have not tried them.
• If pt. will stay long term on CCB, lower the statin dose by half (d/t CCB increasing statin concentration)to minimize side effects
• Good 2nd line drug
• Diltiazem CD:
  - Starting dose 120mg
  - Increase PRN to 180 then 240mg
  - Divide dose if at higher doses (480mg)
• Common side effects: constipation, hypotension. If weird side effects pt may be on a statin and needs to reduce statin dose.

• Very helpful for vestibular migraine or PPPD
• Start at lowest dose 37.5mg, assess response and increase monthly as high as 150mg
• If lower doses needed capsules may be opened and individual beads counted
• Less sedation than tricyclics
• Start with caution as may require long taper to avoid unpleasant withdraw effects

• Very helpful for rocking, less so for Alice in Wonderland displacement in space.
• 0.5mg BID is the max dose I use. If a patient wants more than that it is a red flag for susceptibility to substance abuse.
• 0.5 mg is like drinking 2-3 glasses of wine. Patients should start with ¼ of a 0.5mg tab and increase to find a balance between symptom suppression, anxiolytic effect and ability to function.

• Verapamil (CYP3A4 inhibitor) will enhance the effects of Qulipta
• Abortive- can be used like triptans for headache and VM attacks
  Ubrogepant (Ubrelvy)
  Ubrelvy 100mg is only slightly more effective than 50mg of Ubrelvy, so it is recommended to prescribe 100mg so that the patient can break it in half and have more pills for the month, possibly taking 50mg daily as a preventive
  Rimegepant (Nurtec)
  Ubrelvy 100mg is only slightly more effective than 50mg of Ubrelvy, so it is recommended to prescribe 100mg so that the patient can break it in half and have more pills for the month, possibly taking 50mg daily as a preventive
• Preventative

Atogepant (Qulipta)
There is evidence this decreases vertigo as a migraine symptom when vertigo is present as an aura symptom. This may be true of all CGRP inhibitors.

• An excellent migraine abortive
• For infrequent prolonged attacks use 50mg/d for up to 3d. This often reduces attack duration to 1-2 d.
• 50mg x 3d can help a patient weather an exacerbation of migraine symptoms

• Also helpful for acute attacks as it is anticholinergic and enhances GABA
• Too sedating for long term use
• 25mg q 6 h
• 25mg suppository if vomiting

Consider Allergy Testing elevated histamine in the system is a trigger for migraine

• It is ok to take propranolol during allergy testing and even during immunotherapy, but do not take propranolol on the day of allergy shots to allow for the use of epinephrine if needed in an emergency situation
• Anaphylaxis does not occur with allergy prick and intradermal testing so propranolol does not need to be discontinued for testing
• Migraine symptoms may be excessively aggravated with serum escalation just as during the patients allergy season. Some patients will not tolerate dose escalation until migraine symptoms are partially controlled with medication
• After maintenance is achieved medication taper can be started for many patients if symptoms are controlled

Patients always ask: “Are these medications forever?”. I tell them no. At some point they may be doing so well, with 90+% symptom control, they will ask themselves the very reasonable question; ‘I wonder if I still need these medications?”. If symptoms have been very well controlled for 9-12 months patients typically learn how to prevent occasional breakthroughs as well because they learn to associate breakthroughs with stress, fatigue etc.. Tapering medication in this situation is reasonable. About half find they can get off medications. Half of the remainder find they can maintain their improvement at a reduced dose.

• One in 20-30 patients notices rebound tachycardia with sudden stoppage from 60mg. If this occurs they can resume medication and call. We then taper off propranolol over 5 days using 10 mg tabs.
• Can D/C topiramate with no taper if the patient does not have seizures.
• Wait 5 days after nortriptyline before starting other agents to look for recurrent symptoms that could be misinterpreted as a reaction to the new medication. The half-life of nortriptyline is 72 hours.

If tinnitus fluctuates in intensity (from stress, environmental changes, etc.) and there is no fluctuating process in the inner ear like hydrops, it will usually respond to migraine treatment

• Pre-medicate with prednisone 5 days before surgery to prevent exacerbation of migraine if operating on a migraine sufferer.
• Do not operate if migraines are uncontrolled. Post-op dizziness can set off a migraine storm that can harm the inner ear.

• Place the patient in a supine position (for the lidocaine to reach the SPG)
• Draw up 1.5cc of 2% lido
• With an 18 gauge angiocath:
  - Insert it up under the bridge of the nose:
  - Insert ~1 inch; drip from frontal recess
• Inject 0.75cc on each side
• Lie supine for 3 minutes
• Can repeat frequently

Patients should feel relief within a few minutes; advise patient that throat numbness may make swallowing uncomfortable. Pallor of cheeks is normal because of parasympathetic block.

• “AVULUX” migraine glasses. Also blocks some noxious red wavelengths
  - Axon Optics glasses also excellent
• FL 41 coating on lenses can be ordered by any optometrist
• Green light is soothing for the migraine brain

Constipation can be seen with diltiazem, nortriptyline and CGRP medications. If the medication is effective enough the patient wants to continue it constipation needs to be managed.

• All Bran Buds for fiber loading- most concentrated fiber supplement sold
• Hydrate
• Mg Citrate tablets 400mg. Titrate up to control

The index dose is that dose at which a patient will respond at least some if the drug may be effective for them. If no response to the index dose then do not waste time; move on to the next medication class

• Nortriptyline 20mg
• Topiramate 50mg BID
• Diltiazem 120mg
• Propranolol 60mg
• Verapamil 80mg TID

Chronic fatigue from poor sleep is as common an aggravating factor as hormonal change. Test the potential benefit of better rest with zolpidem 5mg HS for a month. If beneficial and long term help is desired consider meclizine 25-50mg HS as a sleep aid. Meclizine is healthier as a long term sleep aid than hypnotics. The antihistamine effect may also be beneficial.

Many patients with VM have anxiety as a baseline, because of their new symptoms, or both. When anxiety is present clonazepam and propranolol can each play a special role. The anxiolytic effects of clonazepam can help decrease symptom triggering. The GABAergic activity also has a direct effect on symptom intensity in many patients. These combined effects are powerful, allow return to functionality, and justify long-term low dose use in many patients. Since symptoms are still present they can more easily learn to cope with them, and these lower level symptoms can still be used to monitor the efficacy of other agents.

Propranolol is also a useful mood stabilizer in these patients that can be beneficial. By blocking adrenaline during anxiety provoking episodes the patient is permitted to address the event cognitively rather than emotionally. Propranolol is also GABAergic so puts the brakes on central vestibular hyperactivity.

It is difficult to predict what medication will work for a patient as patient may respond uniquely to a single class of medication. Patients also encounter intolerance to medications. A general plan to address all classes of medication should be made at the initial visit knowing there may be 1-5 medications tried. I sketch out a plan A, B, C, D and E and send the patient home. If Plan A medication is intolerable(this may be discovered in a few days) the patient may call and request to move on to plan B. They may also call if there is no noticeable benefit at the index dose in one month. See the patient every 6 or 12 weeks( I prefer 6). This method will allow for identification of an effective regimen within 4 -5 months rather than 1-2 years!

If all classes are tried and have failed the patient, retry classes that were not tolerated with alternative medications. E.g.- could not tolerate topiramate. Circle back and try valproate, an alternate sodium channel blocker.

Patients with chronic and debilitating disease do not need to be carelessly labeled failures when, in fact, a medication has failed them. Deliberately pointing out that “medications have failed them” is a kind awareness your patients will appreciate. Similarly, the term “migraine sufferer” should be used in lieu of the label “migraineur”.

When all else has failed consider less used GABAergic medications in VM patients. Topiramate, Propranolol and Clonazepam all have a role in management and increase GABA activity which is inhibitory to central vestibular pathways. Less often considered are gabapentin, pregabalin, valproic acid and venlafaxine