Brief Answer:
Recommend tracking your headaches more formally

Detailed Answer:
Good evening. My name is Dr. Saghafi and I am a neurologist and headache specialist There are many ways to approach and treat migraine headaches. First, it would be a good idea to be sure that you are in fact having MIGRAINE HEADACHES since sometimes other headache types can appear similar and this could be one reason why medications that are given don't seem to work.

So can you tell me since when you have been suffering from headaches and name me all the different symptoms you may have with these headaches such as nausea, vomiting, extreme sensitivity to light, sound, odors, do you have vertigo, light headedness, numbness, tingling, what is the duration of one of your headaches without treatment, and how many per week do you get? If it is true that your headaches are of the migraine type then, the treatment really should be tailored to your response and adjustments made accordingly.

The way my patients document the course of their headaches is to keep track of them on a diary or headache log. Then, we can see very clearly how the medications are affecting their symptoms and whether or not there is improvement or not which then, allows us to make intelligent changes to the regimen without having to guess as to what the patient is really saying, meaning to say, or did they even remember the right things to tell us since it's been so long since we've seen them, etc.

For example, in your case I see that you are on a very small dose of Inderal and a small dose of Topaz (I don't know if that's the equivalent of TOPAMAX here in the U.S.) but my approach would've been slightly different. I would've stuck with the Inderal and titrated it up slowly over time to see if we couldn't put a halt to your headaches using 1 medication instead of using 2- neither of which are being dosed very adequately for migraine headaches if there is any severity or frequency to these things at all.

I also noticed from the handwritten prescription that you are to take Rizatriptan..is that correct? That is supposed to be a rescue medication in all likelihood....are you taking this during an acute attack? If so, tell me HOW you have been told to take this medication because again, there is a timing factor that should be respected that many people are unaware of doing when it comes to the triptans which can make a difference between therapeutic success and failure.

Since you have someone who is instructing you and following you then, I believe you should speak to them and ask for their advice as well...but by all means feel free to mention what I have said as an option...I would titrate the Inderal to a much higher dose to be taken to see if the headaches could be prevented and not use the Topaz. You must go slowly though...not quickly with the titration otherwise, you could get into trouble. Inderal is actually a blood pressure medication and so can cause you to get very light headed and faint if you push it up too fast or too high.

I'd appreciate the favor of a HIGH STAR RATING with some written feedback assuming you have no further questions or comments.

Also, CLOSING THE QUERY on your end will be most helpful and appreciated so the question can be transacted and archived for further reference by colleagues.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 27 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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Brief Answer:
Thank you for your efforts at getting all those reports and medications

Detailed Answer:
It was very helpful to obtain the reports you did. I would like to give some opinions on the results of the tests and what I think the best approach would be to treat your headaches.

We don't have Vertibil in the U.S. but I looked it up. It is usually given to people who have nausea and vomiting, pain, and vertigo. It is primarily indicated for the vertigo associated with Meniere's disease. I am not of the understanding that you are diagnosed with Meniere's disease nor did you mention anything about symptoms of vertigo. Can you please elaborate on that symptom and how it compares to your actual headaches?

Also, you mentioned that you were given the medication Vertibil based upon the MRI report, however, I've reviewed the reports and I do not find any evidence of abnormalities that would suggest this type of medication would be of benefit.

Also, you've identified several physical factors that are possible triggers for your headaches such as hypoglycemia (skipping food), physical fatigue (incomplete sleep), continuously working on a laptop (eye strain/mental fatigue), extended times in neck flexion, and excessive exposure to sunlight. Therefore, the BEST TREATMENT for those items is to NOT allow them to happen. By ignoring those triggers and then, trying to treat a headache afterwards is much more difficult and not likely to be successful for very long as opposed to avoiding the triggers and subsequently the headache as well as any need then, to treat the headache. Isn't that so much more preferable a scenario?

Therefore, AVOID TRIGGERS is a basic tenet to successful headache treatment.

It appears as if your headaches begin as a neck stiffness or tenseness that radiates to the head causing nausea and vomiting. The medicine Ace-proxyvon relieves the headache while Riazact-10 does not. Ace-proxyvon is an NSAID that contains paracetamol, aceclofenac, rabeprazole,

Therefore, what I gather from the information you've provided is the following:

1. Your scans and labs are normal and do not suggest any pathology in the head or neck. Your labs are also normal and do not suggest any contributory pathology that explains severe migraine headaches.

2. You've got several triggers to your headaches which must be avoided or eliminated and this should be your preferred treatment as opposed to trying and treating the headaches once they've appeared on the heels of the triggers.

3. There is no indication on your diagnostic tests or labs that suggest the need for the drug Vertibil and I suggest you not take this medication for the time being.

And so, I would like to reinforce my original recommendations of increasing your propranolol on a very slow upward titration while holding Topiramate for the time being. I would suggest increasing propranolol by 10mg. weekly per dose until you reach 20 mg. 3x per day. I would then, ask you to keep track of your headaches using a log or diary and see what the changes are in the frequency, duration, and intensity of your headaches in order to gauge the effectiveness of this regimen.

I'd appreciate the favor of a HIGH STAR RATING with some written feedback assuming you have no further questions or comments.

Also, CLOSING THE QUERY on your end will be most helpful and appreciated so the question can be transacted and archived for further reference by colleagues.

Please keep me informed as to the outcome of your situation by writing me at: bit.ly/drdariushsaghafi

All the best.

The query has required a total of 87 minutes of physician specific time to read, research, and compile a return envoy to the patient.

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