Brief Answer:
I would explain as follows:

Detailed Answer:
Hello!

Welcome back on HCM!

I understand your concern and would explain that this dose of nortriptyline is really a low dose and no cardiac adverse effects are supposed to be caused as such dose.

You should know that nortryptiline is a tricyclic antidepressant and can be taken up to a maximal daily dose of 150mg per day.

It is true that it can cause cardio-vascular adverse effects like orthostatic hypotension, ECG changes and tachycardia, but this is usually encountered in high doses and prolonged medications (more than 6-12 months). Adverse effects are usually dose dependent and are more frequent in high doses.

So relax! You have nothing to worry about!

This is the lowest dose possible and it is a capsule, which can not be divided. So you can not start at a lower dose.

I recommend starting this drug at this dose and gradually raise the dose if needed (recommended by your attending physician).

If you experience any troubles like fatigue, dizziness when standing up or tachycardia, you should discuss them with your doctor and perform an ECG.

Drug prescription is based on individual tolerance. If you do not tolerate this drug at such low doses, you can switch to other therapies for vestibular migraines.

Hope you will find this answer helpful!

I am at your disposal for any other questions whenever you need!

Best wishes,

Dr. Iliri

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Brief Answer:
My answer as follows:

Detailed Answer:
Hello again!

Starting at a lower dose will help avoid possible adverse effects, as your body gets used to the drug better, without reacting abnormally (causing adverse effects).

As I already explained the choice of medication should be guided by its side effect profile and the comorbidities of patients. Here are some treatment options for vestibular migraine:

1. Tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam. They are recommended especially when anxiety or depression is present besides headaches and vertigo.
2. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma.
3. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. 4. Calcium antagonists include verapamil and flunarizine. They can cause bradycardia.

Other nonpharmacological measures to prevent migraine with vertigo attacks would be:
- diet modifications: avoid spicy food, caffeine, wine, chocolate
- sleep hygiene. Avoid sleep deprivation. Having a good sleep is very helpful in preventing migraine attacks
- avoidance of migraine triggers (smoking, extreme weather, etc.).

Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

You should discuss on these options with your doctor.

Hope to have been helpful!

Kind regards,

Dr. Iliri

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