What is the diagnosis and treatment for Vestibular (inner ear-related) Migraine?

From the Guidelines

Vestibular migraine is a type of migraine that primarily causes vertigo and dizziness, often without headache, and should be diagnosed using the Barany Diagnostic Criteria, which includes at least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours, and a current or previous history of migraine with or without aura 1.

Diagnosis

To diagnose vestibular migraine, the following criteria should be met:

• At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours
• Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
• One or more migraine features with at least 50% of the vestibular episodes, such as headache with at least two of the following characteristics: one-sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity, photophobia, and phonophobia

Treatment

For acute attacks:

1. Anti-emetics, such as ondansetron 4-8 mg orally or promethazine 25 mg orally, should be used as needed 1
2. Vestibular suppressants, such as meclizine 25-50 mg orally every 4-6 hours, can be used as needed For prevention:
3. First-line treatment should include propranolol 20-80 mg twice daily or topiramate 25-100 mg twice daily 1
4. Second-line treatment can include venlafaxine 37.5-150 mg daily or amitriptyline 10-100 mg at bedtime Lifestyle modifications are also crucial in managing vestibular migraine, including:
5. Maintaining regular sleep patterns
6. Staying hydrated
7. Avoiding known triggers, such as certain foods, stress, and bright lights
8. Practicing vestibular rehabilitation exercises It is essential to evaluate treatment responses shortly after initiation, typically after 2-3 months, and regularly thereafter, every 6-12 months, to assess attack frequency, attack severity, and migraine-related disability 1.

From the Research

Diagnosis of Vestibular Migraine

• Vestibular migraine is a distinct diagnostic entity recognized by the Barany Society and the International Headache Society 2
• Diagnostic criteria for vestibular migraine are available, but challenges to diagnosis include variability in symptoms, duration of attacks, and temporal association between headache and vestibular symptoms 2
• A detailed history and clinical examination are the cornerstone of the diagnostic process, with supportive evidence from audio-vestibular tests and imaging 3

Treatment of Vestibular Migraine

• The treatment of vestibular migraine is a dynamic and rapidly advancing area of research 4
• Patients should follow three steps to control or cure vestibular migraine:
  • Comply with diet and behavioral medication
  • Take medicine to control symptoms during an attack, including antiemetic medications, anti-vertigo medicine, and analgesics
  • Use prophylactic medicine to reduce the frequency and severity of attacks, such as propranolol, topiramate, valproic acid, lamotrigine, and flunarizine 4
• Vestibular rehabilitation (VR) treatment should be considered for all patients with vestibular migraine 4
• Non-pharmacological measures such as diet, sleep hygiene, and avoidance of triggers are recommended, as well as vestibular rehabilitation when there are complications such as loss of confidence in balance or visual dependence 5

Management Strategies

• The mainstay of management is prophylactic medication, with the choice of medication guided by its side effect profile and the comorbidities of patients 5
• Betablockers, anticonvulsants, calcium antagonists, and tricyclic antidepressants are among the medications used for prevention of vestibular migraine 5
• A meta-analysis of preventative treatments for vestibular migraine was published in 2021, but the authors were unable to establish a preferred treatment strategy due to low quality of evidence and heterogeneity of study design and outcome reporting 6