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Suggest Treatment For Persistent Headache When Diagnosed With Perforated Ear Drum
Question: Hi doctor, Im a 37yr old female. i have been suffering for about 6 weeks consistantly with a very heavy head and at time a tension feeling in my head, it mostly stays on the left side of my head where i have a perforated eardrum i had from syringing at my local surgery. i have been taking propanolol for 5 weeks but the headache is still there, it varies in intensity, (mild to moderate) never any sharp pains, but the headache is always there every day. The headache often tends to make me feel disorientated or a feeling of out of focus and lacking in the ability to concentrate, i tend to get very emotional as i'm unsure of what is happening to me. any suggestion of what i can do to help myself, i tried massage therapy, reiki and i'm on these tablets from the GP, who thinks it's a tension type headache. If this is a tension headache will it ever go away :-(
Brief Answer:
Hi Doctor- Hi Patient
Detailed Answer:
Good morning to you across the pond as we prepare to blow off a lot of fireworks today.....not a good day for anybody to be around in this country if you've got headaches. I'm an adult neurologist subspecializing in Headache Medicine so I can tell you that I have many patients similar to your type. I don't believe your perforated eardrum comes into play at all in this case but I do hope that doesn't become too much of a bother for you and you get better from it all the same. Now, of course, do tell me please if there is any synchrony between the time you suffered that popped eardrum and the onset of these headaches. Perhaps, we should give the headache a bit more standing as it relates to what happened....but then, again I would've expected that after 6 weeks things would've calmed down a bit.
Your description of the "heavy head" with at times "tension feeling" could certainly be the type of discomfort that one would feel with a tension type headache. However, the fact, that it wants to remain left sided and continuously seems to be running makes me think of something different. Tension headaches are most typically across both sides of the head and are described by most folk as wearing a TIGHT HAT or feeling as if a vice were squeezing them all around their head. You didn't really describe anything like that so I'm going to simply take your description at your word my dear and throw out another possibility which goes by the name HEMICRANIA. I can't call it HEMICRANIA CONTINUA which is more commonly known among doctors and patients simply because you haven't had the condition long enough.
Please also tell me of any other very uncomfortable symptoms that you've been hiding just because you didn't want to sound like too much the complainer. The Brits are famous for that you know...and we admire that attitude but in this instance I need you to tell me everything you're feeling. Any nausea, vomiting, ringing in the ears, flashing lights, blurry vision, spinning sensations, blacking out or being blind in parts of your visual fields?
Any eye redness and/or tearing, nasal congestion and/or runny nose, drooping eyelid and/or miosis (contraction of the pupil on the affected side). Any forehead sweating throbbing pain, nausea and/or vomiting, or sensitivity to light and sound?
Do you have a history of headaches that you perhaps "grew out of" as a child?
Now, has the propranolol done anything in terms of reduce either the intensity, the duration, or the disabling effects of the headaches? How much of a dose are you on and how many times daily?
To be quite honest, diagnosis a headache you've had continuously for 6 weeks is rather complex since all sorts of things could be different now compared to when these started 6 weeks ago, n'est ce pas? So, in my Headache Clinic here in the States I always distribute a HEADACHE DIARY for people to fill out and if you were my patient that's exactly you'd be doing...a diary with parameters, scores, and comments to make about your headaches daily for a period of 4-8 weeks before really making the call.
However, if I were to put my money on anything on the spur of the moment and without knowing anything else then, I would most entertain the idea of a form of hemicrania but I would want you to document more details in the form of a diary or log. You can find them on the internet or I can send you one. We would then, take a look at the log at about 4 wks from the start and that will easily clinch a diagnosis. Sometimes you'll XXXXXXX the doctor and actually document 2 or more different headache types.
That being said about this likely being more hemicrania than anything else I will also say that I would want to still consider tension headache as a variant since I don't know what the percentage of headaches are that you have on the same side and how many on the opposite.
And so there are several options to try at this point working with just what you've got from the doctor.
1.You could ask the doctor to raise the propranolol to at least 2-3x/day since I suspect you are at a very low dose.
2. The doctor could try you on a medication called indomethacin. However, that medicine gives a lot people a big belly ache so you should start LOW and go SLOW. I always being folks out at 25 mg. once daily x1 week then, 2x daily for another week and then, finally if you're tolerating everything well go to 3x daily with that dose.
3. The doctor could try you on something called nortriptyline and start an upward titration schedule starting with what I usually give most people which would be 10mg at bedtime x 1 week then, 20mg. at bedtime x1w then, 30mg. at bedtime and so on and son on till you get to 50mg. nightly. I would then stay at that level for a good while and DOCUMENT YOUR HEADACHES.
There are more alternatives. And finally, to answer your question about this thing going away....it just all depends on how successful we are at finding the right medication to stop it...doesn't it?
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 49 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Hi Doctor- Hi Patient
Detailed Answer:
Good morning to you across the pond as we prepare to blow off a lot of fireworks today.....not a good day for anybody to be around in this country if you've got headaches. I'm an adult neurologist subspecializing in Headache Medicine so I can tell you that I have many patients similar to your type. I don't believe your perforated eardrum comes into play at all in this case but I do hope that doesn't become too much of a bother for you and you get better from it all the same. Now, of course, do tell me please if there is any synchrony between the time you suffered that popped eardrum and the onset of these headaches. Perhaps, we should give the headache a bit more standing as it relates to what happened....but then, again I would've expected that after 6 weeks things would've calmed down a bit.
Your description of the "heavy head" with at times "tension feeling" could certainly be the type of discomfort that one would feel with a tension type headache. However, the fact, that it wants to remain left sided and continuously seems to be running makes me think of something different. Tension headaches are most typically across both sides of the head and are described by most folk as wearing a TIGHT HAT or feeling as if a vice were squeezing them all around their head. You didn't really describe anything like that so I'm going to simply take your description at your word my dear and throw out another possibility which goes by the name HEMICRANIA. I can't call it HEMICRANIA CONTINUA which is more commonly known among doctors and patients simply because you haven't had the condition long enough.
Please also tell me of any other very uncomfortable symptoms that you've been hiding just because you didn't want to sound like too much the complainer. The Brits are famous for that you know...and we admire that attitude but in this instance I need you to tell me everything you're feeling. Any nausea, vomiting, ringing in the ears, flashing lights, blurry vision, spinning sensations, blacking out or being blind in parts of your visual fields?
Any eye redness and/or tearing, nasal congestion and/or runny nose, drooping eyelid and/or miosis (contraction of the pupil on the affected side). Any forehead sweating throbbing pain, nausea and/or vomiting, or sensitivity to light and sound?
Do you have a history of headaches that you perhaps "grew out of" as a child?
Now, has the propranolol done anything in terms of reduce either the intensity, the duration, or the disabling effects of the headaches? How much of a dose are you on and how many times daily?
To be quite honest, diagnosis a headache you've had continuously for 6 weeks is rather complex since all sorts of things could be different now compared to when these started 6 weeks ago, n'est ce pas? So, in my Headache Clinic here in the States I always distribute a HEADACHE DIARY for people to fill out and if you were my patient that's exactly you'd be doing...a diary with parameters, scores, and comments to make about your headaches daily for a period of 4-8 weeks before really making the call.
However, if I were to put my money on anything on the spur of the moment and without knowing anything else then, I would most entertain the idea of a form of hemicrania but I would want you to document more details in the form of a diary or log. You can find them on the internet or I can send you one. We would then, take a look at the log at about 4 wks from the start and that will easily clinch a diagnosis. Sometimes you'll XXXXXXX the doctor and actually document 2 or more different headache types.
That being said about this likely being more hemicrania than anything else I will also say that I would want to still consider tension headache as a variant since I don't know what the percentage of headaches are that you have on the same side and how many on the opposite.
And so there are several options to try at this point working with just what you've got from the doctor.
1.You could ask the doctor to raise the propranolol to at least 2-3x/day since I suspect you are at a very low dose.
2. The doctor could try you on a medication called indomethacin. However, that medicine gives a lot people a big belly ache so you should start LOW and go SLOW. I always being folks out at 25 mg. once daily x1 week then, 2x daily for another week and then, finally if you're tolerating everything well go to 3x daily with that dose.
3. The doctor could try you on something called nortriptyline and start an upward titration schedule starting with what I usually give most people which would be 10mg at bedtime x 1 week then, 20mg. at bedtime x1w then, 30mg. at bedtime and so on and son on till you get to 50mg. nightly. I would then stay at that level for a good while and DOCUMENT YOUR HEADACHES.
There are more alternatives. And finally, to answer your question about this thing going away....it just all depends on how successful we are at finding the right medication to stop it...doesn't it?
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 49 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hi Dr Saghafi
In Response to your question about the perforation, it was about 3 yrs ago, and no synchrony with the eardrum injury and the headache. the headache started at the back of my head for the first few days then suddenly got intense where i was feeling the tension and heavy headed feeling all over my head, and that's when the loss of focus and concentration came on. I haven't felt any of the symptoms you mention above to be associated with my headache, also I've never had any stabbing, sharp or jolting pains whatsoever, since this headache started, only a heavy and tightening feeling which i describe as a tension feeling.
The tension does move around, sometimes it moves to the crown of my head and into the forehead and sinus, when it's intense I get a slight visual strain. I am on 20mg of propanalol daily, 10mg in the morning and 10mg in the evening, this has somewhat helped the intensity of the headache and I have a few days when its to a tolerable level and the tension and heavy head feeling is hardly noticeable but I still have the lack of concentration and focus although its minimized. I had one day about 3 days ago when I felt I was very close to my normal self again, i.e(the headache hardly noticeable and concentration and ability to focus felt fine) but it came back the following day but not intense, I do get a few manageable days as well as down ones. Hope I've clarified what you were asking.
look forward to your response
Many thanks
In Response to your question about the perforation, it was about 3 yrs ago, and no synchrony with the eardrum injury and the headache. the headache started at the back of my head for the first few days then suddenly got intense where i was feeling the tension and heavy headed feeling all over my head, and that's when the loss of focus and concentration came on. I haven't felt any of the symptoms you mention above to be associated with my headache, also I've never had any stabbing, sharp or jolting pains whatsoever, since this headache started, only a heavy and tightening feeling which i describe as a tension feeling.
The tension does move around, sometimes it moves to the crown of my head and into the forehead and sinus, when it's intense I get a slight visual strain. I am on 20mg of propanalol daily, 10mg in the morning and 10mg in the evening, this has somewhat helped the intensity of the headache and I have a few days when its to a tolerable level and the tension and heavy head feeling is hardly noticeable but I still have the lack of concentration and focus although its minimized. I had one day about 3 days ago when I felt I was very close to my normal self again, i.e(the headache hardly noticeable and concentration and ability to focus felt fine) but it came back the following day but not intense, I do get a few manageable days as well as down ones. Hope I've clarified what you were asking.
look forward to your response
Many thanks
Brief Answer:
Probable tension type headache evolved
Detailed Answer:
Thank you for the clarification. I hope you can appreciate now how valuable a headache log can be. You've now described something materially different from your 1st message based on my questions. You should be documenting your symptoms on a diary that a doctor can interpret. Of course, it depends on how much the interest the doctor has in reading the notes as to of what value such paperwork can have. You'd be most likely in finding a headache specialist as they will understand the detail of what you're doing.
In this case, it now appears to me that you may have started with an occipital neuritis vs. neuralgia but then, it evolved into a full blown tension type headaches. Your doctor therefore, was right with the headache type that you currently have, however, the use of propranolol is not the best first line drug you could be using. You may get benefit from it but if so, it would have to be at a higher dose and dosing frequency.
However, a much more frequently used medication for tension type headaches is nortriptyline which is uptitrated typically from 10mg. at bedtime up to 50mg. on a weekly basis by adding 10mg. You should be documenting your headaches on a log as well as at what point you start your medication and when you increase at each point. It'll take a few weeks of titration before you'll start to notice a significant decrease but it will come about.
If you feel you have your eye strain involved then, I recommend you get your visual acuity checked by an ophthalmologist before taking any other medication or doing anything else. Obviously, if you need corrective lenses or a change to an existing prescription then, headaches can literally vaporize. This idea seems more plausible in the face of the fact that your headaches only started a few weeks ago.
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 73 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Probable tension type headache evolved
Detailed Answer:
Thank you for the clarification. I hope you can appreciate now how valuable a headache log can be. You've now described something materially different from your 1st message based on my questions. You should be documenting your symptoms on a diary that a doctor can interpret. Of course, it depends on how much the interest the doctor has in reading the notes as to of what value such paperwork can have. You'd be most likely in finding a headache specialist as they will understand the detail of what you're doing.
In this case, it now appears to me that you may have started with an occipital neuritis vs. neuralgia but then, it evolved into a full blown tension type headaches. Your doctor therefore, was right with the headache type that you currently have, however, the use of propranolol is not the best first line drug you could be using. You may get benefit from it but if so, it would have to be at a higher dose and dosing frequency.
However, a much more frequently used medication for tension type headaches is nortriptyline which is uptitrated typically from 10mg. at bedtime up to 50mg. on a weekly basis by adding 10mg. You should be documenting your headaches on a log as well as at what point you start your medication and when you increase at each point. It'll take a few weeks of titration before you'll start to notice a significant decrease but it will come about.
If you feel you have your eye strain involved then, I recommend you get your visual acuity checked by an ophthalmologist before taking any other medication or doing anything else. Obviously, if you need corrective lenses or a change to an existing prescription then, headaches can literally vaporize. This idea seems more plausible in the face of the fact that your headaches only started a few weeks ago.
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 73 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Hello Dr Saghafi,
Thank you so much for all your help so far.
I have been back to see my gp following your last response. he has instantly decided to increase the dosage of the propranolol from 20mg a day to 40mg three times daily, he also prescribed amitryptiline 10mg before bedtime, which he says is an alternative drug to nortriptyline, which is preferred over in the UK due to less side effect, but does the same thing nortriptyline. I would like your opinion on this as I feel like this is too many drugs all at once. I've decided to hold off taking them as I wanted your feedBack.
Pls help as I'm now frustrated and don't have much confidence in my gp. I will be booking to see a headache specialist but want your opinion on this first.
Many thanks again, and I'll definitely be writing you a review as I feel your an extremely knowledgeable and understanding doctor.
Thank you so much for all your help so far.
I have been back to see my gp following your last response. he has instantly decided to increase the dosage of the propranolol from 20mg a day to 40mg three times daily, he also prescribed amitryptiline 10mg before bedtime, which he says is an alternative drug to nortriptyline, which is preferred over in the UK due to less side effect, but does the same thing nortriptyline. I would like your opinion on this as I feel like this is too many drugs all at once. I've decided to hold off taking them as I wanted your feedBack.
Pls help as I'm now frustrated and don't have much confidence in my gp. I will be booking to see a headache specialist but want your opinion on this first.
Many thanks again, and I'll definitely be writing you a review as I feel your an extremely knowledgeable and understanding doctor.
Brief Answer:
Nortriptyline side effect profile
Detailed Answer:
Thank you for your updated information.
Once again, in my headache clinic and according to the information you've presented I likely would not've chosen propranolol since that is typically seen in the setting of MIGRAINE HEADACHES....not daily headaches of a NON-migrainous type.
Having said that, all patients must understand that each practitioner's license to practice is also a license to be creative which is what the Art of Medicine is all about. Therefore, in this practitioner's opinion he believes propranolol is your best choice. Therefore, you should either discuss that with him or simply follow his lead.
If I were to use propranolol as he's recommending I may have also more SLOWLY titrated the dose since it is a blood pressure medication which can bring your mood down a bit as well....so as to avoid too many complicating factors occurring at once....I probably would've increased a bit slowly to 30mg. 3x/daily over a period of 2-3 weeks then, if necessary 40mg. 3x/day.
At the same time I would ask you to be keeping track on a log of your headache parameters and to also mark exactly the days that you are CHANGING your medication dose from 20-30 and from 30-40.
As far as his explanation of nortriptyline is concerned; all I can tell you is that in my experience and in the published literature the overall consensus in the U.S. is that nortriptyline (being a next generation AFTER amitriptyline) is felt to be better in terms of reduced intensity of side effects compared to the more standard PROTOTYPE and FIRST DRUG in its class that was ever used to treat daily headaches which is AMITRIPTYLINE. The vast majority of my patients can at least better tolerate nortriptyline compared to amitriptyline which they often times ask me to discontinue because it just doesn't set well with them.
Again, this is a matter of style and choice so how to handle this information is up to you but as far as I'm concerned I'm simply answering your question as opposed to presuming to make any recommendations for treatment beyond the advantage your primary doctor has of having you in front of them.
I can tell you that in the U.S. Amitriptyline is the most commonly used drug for prophylaxis purposes as here when there are daily headaches AND IT IS THE LEAST COSTLY. Nortriptyline is actually more expensive and without making any judgments further of why YOUR provider made the choice he made I can tell you that in this country when insurance companies have a choice between Amitriptyline vs. Nortriptyline for the same diagnosis they ALWAYS choose amitriptyline because of reduced cost. I have treated a number of UK patients and have my own ideas as to why amitriptyline is chosen over nortriptyline but again, that's more a discussion you need to have with them as opposed to my making some type of firm recommendation for treatment. I'm not the treating doctor.
If I were treating a patient in this circumstance (and as I've indicated before) a HEADACHE DIARY is tantamount to any further appointments in my clinic! HAHA! No Headache Diary...."no visits for you my little pretty...", said the Wicked Doctor of the West! LOL......I truly believe the heart of any good headache diagnosis and treatment strategy is only as good as the referred information from the patient. And the BEST and most accurate information can only come from patients who:
1. Understand a little bit about their headaches and why they should be documenting them.
2. The diligence and scrutiny with which the patients strive to create as accurate a record as possible for the doctor
3. And the diligence and scrutiny with which the DOCTOR cares to review and look at the diary the patient has spent time developing.
If there is a breakdown in any one of those 3 elements then, choice of treatments can definitely be compromised and in my opinion, may even be completely missed.
Also, my treatment strategy would be to start 1 medication at a time (unless the patient were suffering from acute and debilitating MIGRAINE SYMPTOMS-- which can actually be risky for other more dangerous consequences).
Therefore, I'd make the choice to START between nortriptyline OR propranolol, uptitrate over a 4-5 week period, fill out the logs, then, step back and see what the REMBRANDT looks like in a month or so. If we still need to fill in a bit of color then, we do...if it looks great as is...then, maybe we take a break from too much more fooling with success and see what happens over the next 2-3 months, if we're not even close then, we need to READ AND ANALYZE our logs more carefully looking for errors in interpretation of the diagnosis or other characteristics of headache that need consideration and make our adjustments from there.
It's really quite sensible and simple yet can go so awry if basic tenets aren't followed.
Of course, I provide this information for your edification not to presume over another colleague's good decision making ability who enjoys other advantages over you compared to myself. Therefore, I'd ask you to consider using this information to educate yourself and become a smarter and better consumer of medical services where you're in the picture while recognizing your doctor's enormous potential for helping you if you place your trust and confidence in them and do their bidding as well.
Cheers!
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 73 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Nortriptyline side effect profile
Detailed Answer:
Thank you for your updated information.
Once again, in my headache clinic and according to the information you've presented I likely would not've chosen propranolol since that is typically seen in the setting of MIGRAINE HEADACHES....not daily headaches of a NON-migrainous type.
Having said that, all patients must understand that each practitioner's license to practice is also a license to be creative which is what the Art of Medicine is all about. Therefore, in this practitioner's opinion he believes propranolol is your best choice. Therefore, you should either discuss that with him or simply follow his lead.
If I were to use propranolol as he's recommending I may have also more SLOWLY titrated the dose since it is a blood pressure medication which can bring your mood down a bit as well....so as to avoid too many complicating factors occurring at once....I probably would've increased a bit slowly to 30mg. 3x/daily over a period of 2-3 weeks then, if necessary 40mg. 3x/day.
At the same time I would ask you to be keeping track on a log of your headache parameters and to also mark exactly the days that you are CHANGING your medication dose from 20-30 and from 30-40.
As far as his explanation of nortriptyline is concerned; all I can tell you is that in my experience and in the published literature the overall consensus in the U.S. is that nortriptyline (being a next generation AFTER amitriptyline) is felt to be better in terms of reduced intensity of side effects compared to the more standard PROTOTYPE and FIRST DRUG in its class that was ever used to treat daily headaches which is AMITRIPTYLINE. The vast majority of my patients can at least better tolerate nortriptyline compared to amitriptyline which they often times ask me to discontinue because it just doesn't set well with them.
Again, this is a matter of style and choice so how to handle this information is up to you but as far as I'm concerned I'm simply answering your question as opposed to presuming to make any recommendations for treatment beyond the advantage your primary doctor has of having you in front of them.
I can tell you that in the U.S. Amitriptyline is the most commonly used drug for prophylaxis purposes as here when there are daily headaches AND IT IS THE LEAST COSTLY. Nortriptyline is actually more expensive and without making any judgments further of why YOUR provider made the choice he made I can tell you that in this country when insurance companies have a choice between Amitriptyline vs. Nortriptyline for the same diagnosis they ALWAYS choose amitriptyline because of reduced cost. I have treated a number of UK patients and have my own ideas as to why amitriptyline is chosen over nortriptyline but again, that's more a discussion you need to have with them as opposed to my making some type of firm recommendation for treatment. I'm not the treating doctor.
If I were treating a patient in this circumstance (and as I've indicated before) a HEADACHE DIARY is tantamount to any further appointments in my clinic! HAHA! No Headache Diary...."no visits for you my little pretty...", said the Wicked Doctor of the West! LOL......I truly believe the heart of any good headache diagnosis and treatment strategy is only as good as the referred information from the patient. And the BEST and most accurate information can only come from patients who:
1. Understand a little bit about their headaches and why they should be documenting them.
2. The diligence and scrutiny with which the patients strive to create as accurate a record as possible for the doctor
3. And the diligence and scrutiny with which the DOCTOR cares to review and look at the diary the patient has spent time developing.
If there is a breakdown in any one of those 3 elements then, choice of treatments can definitely be compromised and in my opinion, may even be completely missed.
Also, my treatment strategy would be to start 1 medication at a time (unless the patient were suffering from acute and debilitating MIGRAINE SYMPTOMS-- which can actually be risky for other more dangerous consequences).
Therefore, I'd make the choice to START between nortriptyline OR propranolol, uptitrate over a 4-5 week period, fill out the logs, then, step back and see what the REMBRANDT looks like in a month or so. If we still need to fill in a bit of color then, we do...if it looks great as is...then, maybe we take a break from too much more fooling with success and see what happens over the next 2-3 months, if we're not even close then, we need to READ AND ANALYZE our logs more carefully looking for errors in interpretation of the diagnosis or other characteristics of headache that need consideration and make our adjustments from there.
It's really quite sensible and simple yet can go so awry if basic tenets aren't followed.
Of course, I provide this information for your edification not to presume over another colleague's good decision making ability who enjoys other advantages over you compared to myself. Therefore, I'd ask you to consider using this information to educate yourself and become a smarter and better consumer of medical services where you're in the picture while recognizing your doctor's enormous potential for helping you if you place your trust and confidence in them and do their bidding as well.
Cheers!
I hope this answer satisfactorily addresses your question. If so, may I ask your favor of a HIGH STAR RATING with some written feedback?
Also, if there are no other questions or comments, may I ask you CLOSE THE QUERY on your end so this question can be transacted and archived for further reference by colleagues as necessary?
Please direct more comments or inquiries to me in the future at:
bit.ly/drdariushsaghafi
I would be honored to answer you quickly and comprehensively.
Please keep me informed as to the outcome of your situation.
All the best.
The query has required a total of 73 minutes of physician specific time to read, research, and compile a return envoy to the patient.
Above answer was peer-reviewed by :
Dr. Chakravarthy Mazumdar
Answered by
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