What are the best medication options for a young female with vestibular (migraine-related vertigo) migraine?

From the Guidelines

For a young female with vestibular migraine, the best medication options include beta blockers, such as propranolol, topiramate, or candesartan as first-line medications, as recommended by the most recent guidelines 1. When considering treatment, it's essential to evaluate the frequency and impact of migraine episodes on daily life. According to the guidelines, preventive treatment should be considered in patients who experience migraine on ≥2 days per month despite optimized acute treatment 1. Some key points to consider when selecting a medication include:

• The use of beta blockers, such as atenolol, bisoprolol, metoprolol, or propranolol, as first-line medications due to their efficacy and relatively favorable side effect profile 1
• Topiramate and candesartan are also recommended as first-line options, offering alternative choices for patients who may not tolerate beta blockers 1
• Second-line medications, including flunarizine, amitriptyline, may be considered if first-line options are ineffective or not tolerated, although their use may be limited by side effects and specific patient factors 1
• CGRP monoclonal antibodies are reserved for third-line treatment, typically for patients who have failed other preventive therapies 1 In clinical practice, the choice of medication should be individualized, taking into account the patient's medical history, potential drug interactions, and specific symptoms. Regular follow-up is crucial to assess treatment efficacy and adjust the therapeutic plan as needed.

From the Research

Medication Options for Vestibular Migraine

• Acute attack treatment:
  • Antiemetic drugs such as diphenhydramine, meclizine, and metoclopramide may be effective 2
  • Migraine-specific medications such as triptans may be effective 3, 4
  • Vestibular suppressants may be considered 4
• Preventive treatment:
  • Metoprolol, amitriptyline, topiramate, valproic acid, or flunarizine may be used for pharmacological prophylaxis 2
  • Propranolol, venlafaxine, topiramate, and amitriptyline may be used for migraine prevention 3
  • Acetazolamide or lamotrigine may be used for refractory patients 3
  • Anti-epileptic drugs such as topiramate and valproate are effective for migraine prophylaxis, but may have serious side effects 5

Non-Pharmacological Measures

• Regular exercise, relaxation techniques, stress management, and biofeedback may be effective and can be combined with pharmacological treatment 2
• Vestibular rehabilitation may be helpful 3
• Lifestyle modification and treatment of comorbidities are important principles of treatment 4