What is the recommended dosing of Nortriptyline (tricyclic antidepressant) for a patient with vestibular migraine?

Nortriptyline Dosing for Vestibular Migraine

Start nortriptyline at 10 mg daily at bedtime and escalate by 10 mg every 2 weeks up to a maximum of 40 mg daily for vestibular migraine prophylaxis. 1

Evidence-Based Dosing Protocol

• Initial dose: Begin with 10 mg nortriptyline at bedtime 1
• Titration schedule: Increase by 10 mg increments every 2 weeks (biweekly escalation) 1
• Target dose range: 10-40 mg daily 1
• Maximum dose for vestibular migraine: 40 mg daily 1

This dosing regimen is lower than traditional migraine prophylaxis (which uses 25-100 mg) 2 but has been specifically validated for vestibular migraine in a 2025 prospective intervention study 1.

Clinical Efficacy Data

• At 4 weeks of treatment with nortriptyline (10-40 mg), dizziness severity decreased from 6.0 to 4.2 on the visual analog scale, though this did not reach statistical significance (p=0.069) 1
• Quality of life improved in 88% of patients treated with nortriptyline alone 1
• The modest efficacy suggests nortriptyline works best when combined with migraine dietary and lifestyle modifications rather than as monotherapy 1

Alternative Prophylactic Medications for Vestibular Migraine

If nortriptyline is ineffective or not tolerated after adequate trial:

• Flunarizine should be considered first-line based on two randomized clinical trials showing superior evidence 3
• Propranolol, topiramate, venlafaxine, and valproic acid are second-line options 3, 4
• Amitriptyline (the parent compound of nortriptyline) at 30-150 mg/day is effective but has more anticholinergic side effects 2, 5, 6, 4
• Lamotrigine is preferred when vertigo symptoms are more frequent than headaches 5, 6

Clinical Decision Algorithm

Step 1: Start nortriptyline 10 mg at bedtime with concurrent implementation of migraine dietary/lifestyle modifications (avoid triggers, maintain sleep hygiene, dietary modifications) 1

Step 2: Escalate dose by 10 mg every 2 weeks based on symptom response and tolerability, up to maximum 40 mg daily 1

Step 3: Assess response at 4 weeks using dizziness severity and quality of life measures 1

Step 4: If inadequate response at 40 mg after 4 weeks, switch to alternative prophylactic agent (flunarizine, propranolol, topiramate, or venlafaxine) rather than exceeding 40 mg 3, 4

Important Considerations for Vestibular Migraine

• Comorbidity-guided selection: Choose nortriptyline specifically when patients have comorbid anxiety or depression, as tricyclic antidepressants address both conditions 5
• Contraindications: Avoid nortriptyline in patients with cardiovascular disease, recent MI, arrhythmias, heart block, or prolonged QTc syndrome 2
• Side effects: Monitor for anticholinergic effects (dry mouth, constipation, urinary retention, blurred vision, confusion), though nortriptyline has fewer anticholinergic effects than amitriptyline 2
• Elderly patients: Nortriptyline is preferred over amitriptyline in elderly patients due to better tolerability 2

Critical Pitfall to Avoid

Do not use standard migraine prophylaxis doses (25-100 mg) for vestibular migraine. 2, 1 The 2025 evidence specifically validates lower doses (10-40 mg) for vestibular migraine, and exceeding 40 mg provides no additional benefit while increasing side effects 1. If symptoms persist at 40 mg, switch to a different prophylactic medication class rather than escalating nortriptyline further 3, 4.

Acute Attack Management

• Triptans can be tried for acute vestibular migraine attacks, though evidence is conflicting 3
• Antivertiginous and antiemetic drugs are used for long-lasting individual attacks 5
• Specific antimigraine drugs are unlikely to be very effective for rescue treatment of vestibular symptoms 5

Non-Pharmacological Adjuncts

• Vestibular rehabilitation is a sound prophylactic treatment option and should be considered, especially when patients have loss of confidence in balance or visual dependence 5, 3, 4
• Migraine dietary and lifestyle modifications (trigger avoidance, sleep hygiene, dietary changes) are highly effective, reducing dizziness from 8.7 to 3.6 (p<0.001) in 4 weeks and should be implemented alongside medication 1