Suggest Treatment For Severe Migraine While On Propranolol

Posted on Sat, 16 Jan 2016

Medically reviewed by Ask A Doctor - 24x7 Medical Review Team

Sat, 16 Jan 2016 Answered on

Fri, 12 Feb 2016 Last reviewed on

Question : I get ocular migraines, just the vision part never any pain of a headache afterwards. Sometimes i have 2 a day for a couple weeks and sometimes i go 3 months without one. I take propranolol and clonozapam which has helped the anxiety part of it alot. I just worry im gonna be driving when it happens. They only last about 15 minutes. Should i get an mri or is this normal. Most of the time it happens around the time of my period, could it be hormonal or could it be from stress. We own 2 body shops and i do all the paper work and its very stressful.

Answered by Dr. Olsi Taka (30 minutes later)

Brief Answer:
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Detailed Answer:
I read your question carefully and I understand your concern.

Propranolol is a good first choice preventive medication, so if you feel that if has made the attacks less frequent then it can be continued. If on the other hand it hasn't had any visible effects then there are other options. Such options might include either another antihypertensive drug like verapamil, or other groups like antidepressants (amitriptyline) or anticonvulsants (valproic acid, topiramate).
However I do not agree with continuing use of clonazepam for anxiety, because while effective in short term, if taken for a long time creates dependence and tolerance (need higher dose to achieve effect). So if anxiety is a chronic issue which requires medication (relaxation techniques, yoga, may be tried first) the more appropriate medication would be antidepressants.

As for the question on MRI, if the migraines are a phenomenon which has appeared only recently then imaging is necessary to exclude it being transient ischemic attacks due to vascular problems. By imaging I mean either Doppler ultrasonography, or angio CT or angio MRI including neck blood vessels.
On the other hand if the migraines have been there for a long time though, say over a year, the chances of that being the cause are slim, it can be skipped.

Regarding the questions about stress or hormones, the answer is both. Migraine attacks can have many triggers, stress and hormonal fluctuations are at the top of the list, both can trigger attacks. Other factors may be certain foods and drinks, so it helps to keep a diary regarding the attacks in order to identify other potential triggers.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Olsi Taka (1 hour later)

I only take 1/2 of a 5 mg of clonozapam 3 times a day is that still not a good idea

Answered by Dr. Olsi Taka (7 hours later)

Brief Answer:
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Detailed Answer:
Hello again.

You say to take 7.5 mg a day and you seem to think it's a small dose, but actually that is not small at all, on the contrary. Usually for anxiety it is started at 0.5-0.75mg a day.
Actually I am wondering if we are speaking of the same drug as I was not aware of there existing 5mg pills of clonazepam, in my country the highest dose in circulation is 2 mg and from a quick search it seems to me in the US too. Please make sure the spelling and dosage is correct.
If indeed you take half of a 5mg pill 3 times daily, yes it is not a good idea, but with such a dose should be very careful for withdrawal symptoms, should consult your physician and should wean very gradually absolutely not right away.

I hope to have been of help.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Olsi Taka (9 hours later)

.5 mg i forgot the . I take half of a .5 mg pill 3 times a day.

Answered by Dr. Olsi Taka (4 hours later)

Brief Answer:
Reasonable dose, but the recommendation remains the same.

Detailed Answer:
Thanks for the update, 0.5mg makes much more sense.

Anyway I still maintain that clonazepam is not a long term solution. It is used for short term treatment of anxiety say for some weeks, but if there is chronic anxiety and long term treatment is predicted, then benzodiazepines like clonazepam are not preferred due to creating dependence and tolerance, it is antidepressants which are preferred instead.

Wishing you good health.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Olsi Taka (1 hour later)

I was on antidepressants for 5 yrs and tried several different kinds, was on citalopram for 3 yrs and it just stopped working and i went into 4 weeks of withdrawl from hell and i didnt just quit cold turkey when it stopped working i kept reducing the amount like told to and i still had withdrawls i had never went thru anything like that before and will never get on an antidepressant again. The propranonlol helped alot just still had that lil anxiety of going in stores or driving by myself and the clonazepam helps that

Answered by Dr. Olsi Taka (13 hours later)

Brief Answer:
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Detailed Answer:
Thank you for the additional information. I understand why you do not want to go the antidepressant path again.
On paper, I still have to say that benzodiazepines like clonazepam have a higher potential for dependence and tolerance development. The longer continued the more difficult the withdrawal process is as well. So try to keep that in mind and if you decide to still take it keep the dose to a minimum like the actual one.
If you ever wonder about a third option apart from antidepressants and benzos for anxiety, a medication called buspirone is a remaining possibility, it doesn't cause the dependence benzodiazepines are known to cause.

I hope things work out for the best.

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar