Brief Answer:
Atypical Migraine vs. Vestibular Migraine or MAV

Detailed Answer:
Many thanks for choosing to send your question to my attention. I am a neurologist and headache specialist in the U.S. I have reviewed your symptoms and rather thorough workup.

Of course, your symptoms could be consistent with any number of problems having to do with other systems of the body such as cardiovascular (i.e. dizziness that is intermittent can be an early sign of Atrial Fibrillation), GI disturbance, autonomic dysfunction, Meniere's disease etc. However, I will assume that other conditions have been already thought of by your primary doctors and we are now looking at primarily the spectrum of neurological entities.

The clean MRI and CT of the head certainly rule out many things that could've been the cause of the symptoms. My first impression then, as a neurologist and headache specialist in the face of all your information is that you are likely suffering from what we would refer to as ATYPICAL MIGRAINE and very possibly VESTIBULAR MIGRAINE (VM) or Migraine Associated Vertigo (MAV)....although in the latter 2 categories severe headaches are in fact frequently seen as part of the picture at some point of illness although what truly distinguishes VM or MAV from other types of migraine headaches which simply have vertigo associated as an aura or symptom is the fact that the HEADACHE and the VERTIGO or IMBALANCE (if not true vertigo) are often separated in time. This means that 1 day there may be a severe migraine headache which resolves....and then, some hours or even 1-2 days later there will be severe VERTIGO...but no headache.

You don't seem to have that picture. That is why I chose ATYPICAL MIGRAINE headache as a more likely first diagnosis on my differential. In this type of headache headache is not always present and in fact, frequently it is NOT present to any extent, however, many rather bizarre and disconnected symptoms that seem to point to even other body systems as I previously stated may be part of the clinical picture. This is what makes ATYPICAL MIGRAINE a good diagnosis and especially when treated with migraine types of medications people often time respond.

In your particular case and because of your symptom of feeling off balance or mildly vertiginous when turning your head I might consider just one other thing if treatments don't seem to work very well....or if they settle down but then, fire back up again....and that is a condition called BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV). I have a rather low index of suspicion for this entity given the other more likely possibilities but nonetheless I would keep that in the back of my mind (as likely your doctors have already considered) and if necessary pull it out for investigation at a future date. The test for that entity would be performing a very and quick bedside maneuver called a Dix-Hallpike test to see if any symptoms or even nystagmus of the eyes can be elicited. If the test is positive then, a remedial maneuver known as the EPLEY MANEUVER or MODIFIED EPLEY is employed. However, again, I only include this diagnosis for the sake of completeness.

In my practice I am a HUGE fan of my patients keeping a HEADACHE DIARY or LOG which you can print from the internet...and to document their symptoms at baseline and following treatments which can help us determine if things are going the right way. In the case of ATYPICAL MIGRAINE...we often use the exact same types of drugs we use in TYPICAL migraines except there may be some variation to drugs added in the event there were nausea, vomiting, etc.

I noticed you said that your B12 levels were low but I didn't hear you mention anything of VITAMIN D nor did you mention anything to do with your thyroid hormones. Therefore, I would also make sure BEFORE using medications that metabolic parameters have been optimized. My preference for Vitamin D levels (despite what many NON-neurology physicians and laboratories consider as normal) are levels of 60-80. My threshold for B12 these days is higher than it was in the past as well.....400+, and when testing for thyroids I always START with a TSH and FT4...many people only screen with a TSH....but this will miss some patients who are either HYPER or HYPO-thyroid if only TSH is used as the marker,.

I always check my patients for elements of GOOD NUTRITION AND HYDRATION. We do orthostatic BP's on them to make sure they are drinking adequate fluids and have diets that are healthy and take into account what are believed to be some of the most common food and beverage triggers in migraine patients.

When it comes to medications if there are clearly no headaches in the attack per se and the condition is chronic (i.e. daily for at least 3 months) then, we usually start with a prophylactic regimen of PROPRANOLOL at 10mg. daily and escalate up to as much as 120 mg. in divided daily doses. If that does not significantly reduce symptoms then, another prophylactic that can be tried would be TOPIRAMATE. We usually start at 50mg. twice daily if symptoms are moderate or severe and interfere with activities. If they are mild or as in your case resolving then, perhaps 25mg. twice daily would be sufficient.

If there are ACUTE attacks that involve actual headaches along with the symptoms you describe then, drugs of choice would include things such as SUMATRIPTAN, NARATRIPTAN, or RIZATRIPTAN. There are others from this class...but these are my 3 top choices to start.

I do not have any experience with some of the medications you mention since they are not considered part of the standard medication protocols here such as sibelium or Zerodol therefore, I don't know if that is similar or just another name for any of the triptan medications I've mentioned up top in terms of acute drugs for instantaneous attacks. Ibuprofen certainly sounds like a medication we use extensively in this country for headache attacks, and while it can work for specific headaches I would be cautious as to HOW much were used because OVERUSE can cause worsening headaches, more frequent other symptoms, and eventually refractoriness to treatment. It should also always be taken with food and not on an empty stomach as it can cause gastric distress and in some case of chronic use, ulcerations to form.

If you have been under a lot of stress then, I would look for someone who can teach you techniques of relaxation using breathing maneuvers, biofeedback, and even acupuncture which can help a lot of people. You will put a lot of these techniques to very good use in the military when you need to be able to separate yourself for a bit of a time out due to stress or anxiety.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 60 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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Brief Answer:
Atypical Migraine

Detailed Answer:
Please the following responses to each of your questions:

I did take a Vitamin D and Thyroid tests ,forgot to mention them - Both came back normal. Vitamin D was slightly low for which I had started taking Vitamin D supplements.

>>>>>MY THRESHOLD FOR VITAMIN D BEING IN GOOD RANGE IN PATIENTS WITH NEUROLOGICAL CONDITIONS IS WHEN IT IS 60-80. IF YOUR VITAMIN D LEVELS ARE LESS THAN 60 THEN,, I WOULD WORK ON REPLACING.



I have been recently a week ago been put on a course of PROPRANOLOL-40 mg every night as recommended by my Neurologist and I do get a general sense that it is working better than Sibelium (Flunarizine 10mg).

>>>>>>>I BELIEVE PROPRANOLOL IS A VERY GOOD PROPHYLACTIC MEDICATION, HOWEVER, I TEND TO PRESCRIBE IT IN A DIVIDED DOSE PLAN THAT CAN GO AS HIGH AS 40MG. 3X/DAY. MY REGIMEN STARTS AT 10MG. 3X/DAY AND IS INCREMENTED WEEKLY. YOU SHOULD FOLLOW YOUR NEUROLOGIST'S REGIMEN. EACH CLINICIAN HAS A DIFFERENT APPROACH.

The strange fact is after taking Propranolol the pain I used to get behind my left eye seems resolving - Can a migraine induce or mimic a Nerve pain? (I took Eye muscle exam tests and that came back normal as well).

>>>>>>>> MANY MIGRAINEURS (even those with ATYPICAL migraine) COMPLAIN OF PAIN BEHIND THE EYES OF A SHARP NATURE. IF STARTING PROPRANOLOL HAS HELPED THIS CONDITION THIS THEN, THIS COULD BE A SIGN THAT THE HEADACHE TYPE IS COMING UNDER CONTROL.

Generally I wake up OK and within lets say 20 minutes the lightheaded feeling creeps over - Should I still consider taking Propranolol only during night time? or should I take it whenever I get these strange /disconnected feeling?

>>>>>>>>>PROPRANOLOL, AS ALL OTHER MEDICATIONS WHICH ARE DESIGNATED AS PROPHYLACTIC, TAKING THEM ON AN 'AS NEEDED BASIS' IS NOT APPROPRIATE FROM A PHARMACOLOGICAL POINT OF VIEW. IF YOUR SYMPTOMS ARE NOT PERFECTLY CONTROLLED YOU NEED TO MENTION THIS TO YOUR NEUROLOGIST SO THEY CAN ADJUST EITHER THE DOSE, DOSING REGIMEN, CHOICE OF MEDICATION, OR POTENTIALLY ADDITION OF AN ACUTE MEDICATION FOR YOUR CONDITION.

There is also one point I place a lot of emphasis on in my patient population and that is an analysis and modification of diet in order to correct things that could represent food allergies, food triggers, etc. This tends to improve and sustain headache conditions as well (if not better in some cases) than medication. Also, exercise is key, good weight management, and good cardiovascular tone. You should seek detailed counseling in these areas if your neurologist is not used to managing these things in their patients....but they are clearly important and can impact long term outcomes.

If I've provided useful and helpful information to your questions could you do me a huge favor by CLOSING THE QUERY and be sure to include some fine words of feedback along with a 5 STAR rating? Again, many thanks for submitting your inquiry and please let me know how things turn out.

Do not forget to contact me in the future at: www.bit.ly/drdariushsaghafi for additional questions, comments, or concerns having to do with this topic or others.

This query has utilized a total of 80 minutes of professional time in research, review, and synthesis for the purpose of formulating a return statement.

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