#nortriptyline

I had been doing so well, missing 1 or 2 days of work each month because of migraines rather than weeks at a time. I was finally accruing vacation time again but now...it's going to be depleted because of my being in the hospital this week and they're going to give me a week off whenever they discharge me; time I have to take out of vacation that I've earned which means I'm going to lose it all.

Interview season was actually kind of fun because I got to go to a lot of cities that I’ve never been to before. But it definitely got old real fast. Gaining weight from the free alcohol and dinners/lunches along with being in the car all day with fast food hasn’t been the greatest. 

I’ve been under a lot of stress because I haven’t decided upon my rank list. To follow my SO to his program or not. I’ve never made such a big commitment before. It’s a program that would have been my first or second choice anyways but there’s that what if that’s bothering me. What if I go there and we break up but then I have to see him around the hospital. What if I hate it there and resent him for it. What if I go somewhere else and our relationship suffers greatly because of the long distance. I’ve been avoiding researching my programs for the nuances to move them up or down now because it makes me so anxious. Maybe I should have done a wine night tonight to look at them. 

Lastly, there’s the struggle with the headaches again ever since I switched from amitriptyline to depakote. I have gained so much weight on depakote and it doesn’t even help me. So my self confidence is pretty damn low lately. I finally talked to a therapist about all this and she said that she thinks I’m both burned out and perhaps depressed. Constant headaches and stress will do that to you, I supposed. My new neurologist switched me to nortriptyline because he said it’s less sedating than amitriptyline (which is why I switched from the first place, to be able to stay up all night during residency). He doesn’t care for propranolol or zonegran that much so I picked nortriptyline. And gave me zumatriptan which I’m not sure how often I’m supposed to take because he wrote me for 4 of them. I hope it doesn’t make me that drowsy so I can work 24s. 

Vestibular migraine has been also called migraine-associated vertigo or dizziness and migrainous vertigo. Diagnostic criteria, according to the international headache classification, include a current or past history of migraine with or without aura, attacks lasting between 5 minutes and 72 hours, vestibular symptoms of moderate or severe intensity. These vestibular symptoms include spontaneous vertigo, positional vertigo occurring after a change of head position; vertigo triggered by a complex or large moving visual stimulus, head motion-induced vertigo occurring during head motion, head motion-induced dizziness with nausea. There is also a requirement for at least half of episodes to be associated with a typical migraine headache or visual aura.

These criteria are the result of a consensus arrived at by headache specialists, which makes them based on cases seen by these specialists, rather than large scientific studies. I’ve encountered some patients who do not have migraine headaches or visual auras, but probably still suffer from migraine-related dizziness or vertigo.

We also lack any studies of treatment for patients with vestibular migraine. My own observation is that vestibular symptoms improve with the treatment of migraine headaches. In patients who suffer from vestibular symptoms with few or no headaches we try similar treatments first – magnesium, CoQ10 and other supplements (we often check blood levels of RBC magnesium and CoQ10), regular aerobic exercise, and medications, such as gabapentin and nortiptyline. When headaches are very frequent we give Botox injections, which are not appropriate if headaches are infrequent.

The classification of headaches also lists benign paroxysmal vertigo as a condition which occurs in children and which may be associated with migraines. (This is different from benign positional vertigo which is triggered by a loose crystal in the inner ear and which can be cured with the Epley maneuver). This migraine-related vertigo usually occurs without a warning and resolves spontaneously after minutes to hours without loss of consciousness. Patients usually have one of the following features: nystagmus (beating movement of the eyes to one side), unsteadiness, vomiting, paleness, or fearfulness. The neurological examination, audiometry (hearing test) and vestibular functions (test also done by an ENT specialist) are normal between attacks.

I've been struggling with having cut back my nortriptyline to 75mg from 100mg after my tachycardia event. I went back on 100mg about 2 days ago because 75mg just wasn't cutting it for me mentally and emotionally. I'm making sure I'm drinking a lot of water because I'm starting to suspect being dehydrated might have caused my tachycardia. Before I landed in the ER and subsequently the hospital, I had a migraine for 2 days straight and I know I didn't drink enough as I practically slept for those 2 days. Nortriptyline is known for having dry mouth as a side effect so I can't help but wonder if the nortriptyline caused me to be severely dehydrated and sent my body into tachycardia.