Migraine Management

Good Cop ?  Bad Cop ? — It’s your Headache

This week we have a contribution from Tom Boismier, a vestibular specialist in Fort Wayne, Indiana.  He offers an interesting perspective on counseling the patient with suspected vestibular migraine. As you may have read in the previous series, Migraine is a common cause of dizziness.

Here’s Tom:


None of the neurologists in our area specialize in treating either migraine or vertigo, so they are happy to let us manage these patients. We decided on amitriptyline and Topamax as our prophylactics of choice after consulting with the local neurology group. Our nurse practitioner handles most of our migraine management. Julie came to us from neurology, has an interest in migraine and has done quite a bit of CME training on migraine management.

I tend to take the “bad cop” approach when counseling migraine patients. I tell them that they are best off avoiding ALL migraine triggers until it is obvious that they are better (by the headache diary they have to keep). Once improvement is obvious, then they can add items back one at a time to determine which they are sensitive too. The “good cop” approach of stopping one trigger at a time takes a VERY long time, especially in those with chronic daily headache.

Go to bed at the same time every night, get up at the same time every day. (good cop: try to get enough sleep…)

Strictly avoid all OTC analgesic and sinus medications for at least 1 month. (good cop: try to cut down…)

Most patients get both the bad cop talk from me and the good cop talk from Julie or one of our docs, so I tell them that their improvement is in their hands. The more of these things they do, the faster they improve and the closer to 100% better they get.

We do use VRT in conjunction with migraine management when symptoms indicate that it may help. Some migraine patients will not progress in VRT until the underlying migrainous vasospasms are better controlled, so we give the PT full license to put VRT on hold if she sees no improvement and/or if it aggravates headache.

We give our migraine patients a series of handouts, including Dr. Hain’s MAV webpage, the 1995 Postgrad Med article, and our version of the headache diet.

Our mainline medications are Topamax and amitriptyline, which any of our ENTs feels pretty comfortable prescribing. Amitriptyline is especially helpful for those with comorbidity of depression or sleep problems (take it at bedtime…). Our neurotology NP will also use Effexor, and occasionally Inderal LA if the first two fail. She will refer them to neurology at that point and start them on one of these while they are waiting for their neuro appt.

All are started at a very low dose, with dosage incremented once per week until one of three things happens: excellent headache control (that’s why you need a diary…), intolerable side effects or max dose reached without benefit.

Topamax is started at 25 mg/day. After 7 days increase by 25 mg/day up to max 100 mg/day. Amitriptyline starts 10 mg/day, increase 10 mg up to 40 mg/day max. Effexor 37.4 mg.day, increase 37.4 up to 149.6/day max. Inderal LA 60 mg/day, increase 60 up to 240 mg/day max.

In our experience, prophylaxis alone is not enough for folks who have frequent headaches. They MUST follow the behavioral changes as well, especially avoiding analgesics. If the history suggests transformed migraine (headache/head pressure events more than twice a month, plus use of analgesics more than twice a week) I use the following macro in the recommendations section of my report:

BREAK THE HEADACHE CYCLE. Consider complete avoidance of OTC analgesics for at least one month, limiting use of prescription abortive migraine agents to no more than twice a week, and daily migraine prophylaxis. Restrict the use of caffeine, avoid migraine triggers, maintain  regular sleep habits and keep a headache diary. Should this fail to decrease headache frequency, consider referral to a subspecialty headache clinic.

If twice a month or less:  ADDRESS HEADACHE. Restrict the use of analgesics and caffeine, avoid migraine triggers, maintain regular sleep habits and keep a headache diary. Consider a trial of daily prophylactic migraine medication.

It is important to remember that people more often than not SELF-DIAGNOSE their headache, and their medical providers simply agree with that diagnosis without any workup. The self-diagnosis is usually sinus, and usually wrong (studies suggest 80% to 90% of the time…).

Bottom line: don’t take the patient’s label for their headache at face value, confirm by taking a full headache history, and, if necessary, get a CT sinus to rule sinus in or out. As Dr. House likes to say, patients lie …


About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.