From the Guidelines
For a 45-year-old male recently diagnosed with vestibular migraines, the most effective treatment approach is to start with preventive medications such as candesartan or telmisartan, as recommended by the 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense clinical practice guideline for the management of headache 1.
Preventive Medications
The guideline strongly recommends candesartan or telmisartan for the prevention of episodic migraine, which can help reduce the frequency and severity of attacks. Additionally, erenumab, fremanezumab, or galcanezumab may be considered for the prevention of episodic or chronic migraine.
Acute Treatment
For acute treatment during an episode, medications such as eletriptan, frovatriptan, rizatriptan, sumatriptan, or zolmitriptan may be effective, as recommended by the guideline 1. Aspirin-acetaminophen-caffeine is also a recommended option for the short-term treatment of migraine.
Lifestyle Modifications
Implementing lifestyle modifications, such as:
- Regular sleep patterns
- Stress reduction techniques like meditation
- Avoiding known triggers such as certain foods, bright lights, or loud noises
- Keeping a migraine diary to identify specific triggers can help improve symptoms and quality of life.
Vestibular Rehabilitation
Vestibular rehabilitation exercises, prescribed by a physical therapist, can help improve balance and reduce dizziness associated with vestibular migraines.
Supplements and Additional Treatments
Some patients may find relief with supplements like magnesium or Coenzyme Q10, but it is essential to consult a doctor before starting any supplements. If symptoms persist or worsen, additional treatments such as Botox injections or newer CGRP antagonists may be considered. Regular follow-ups are crucial to adjust the treatment plan as needed.
From the FDA Drug Label
The efficacy of rizatriptan benzoate orally disintegrating tablets in pediatric patients 6 to 17 years was evaluated in a multicenter, randomized, double-blind, placebo-controlled, parallel group clinical trial (Study 7) Patients had to have at least a 6 month history of migraine attacks (with or without aura) usually lasting 3 hours or more (when untreated). The patient population was historically non-responsive to NSAIDs and acetaminophen therapy. Patients were instructed to treat a single migraine attack with headache pain of moderate to severe intensity.
The treatment options for a 45-year-old male recently diagnosed with vestibular migraines are not directly addressed in the provided drug labels. However, rizatriptan may be considered for the treatment of migraines.
- The efficacy of rizatriptan benzoate was evaluated in clinical trials for the treatment of migraine attacks.
- Contraindications for rizatriptan benzoate include ischemic coronary artery disease, coronary artery vasospasm, history of stroke or transient ischemic attack, peripheral vascular disease, ischemic bowel disease, uncontrolled hypertension, and recent use of another 5-HT1 agonist or ergot-type medication 2, 2. It is essential to consult the patient's medical history and current health status to determine the best course of treatment.
From the Research
Treatment Options for Vestibular Migraines
The treatment options for a 45-year-old male recently diagnosed with vestibular migraines include:
- Pharmacological measures:
- Acute attack treatment: antiemetic medications (e.g., dimenhydrinate and benzodiazepines), anti-vertigo medicine, and analgesics (e.g., triptans) 3
- Prophylactic medication: betablockers (e.g., propanolol or metoprolol), anticonvulsants (e.g., topiramate, valproic acid, and lamotrigine), calcium antagonists (e.g., verapamil and flunarizine), and tricyclic antidepressants (e.g., amitryptiline or nortryptiline) 4, 5, 6, 7
- Non-pharmacological measures:
Considerations for Treatment
When choosing a treatment option, considerations should be made for:
- Side effect profile of the medication 4
- Comorbidities of the patient (e.g., hypertension, asthma, anxiety, or depression) 4, 5, 6
- Frequency and severity of vertigo symptoms 5, 3
- Patient's response to treatment and potential need for polytherapy 6
Efficacy of Specific Treatments
Studies have shown that:
- Topiramate and flunarizine hydrochloride are effective in reducing vertigo intensity, duration, and frequency in VM patients 7
- Topiramate may be superior to flunarizine hydrochloride in reducing vertigo symptoms, but not in improving mood 7
- Vestibular rehabilitation may be helpful in improving balance and reducing symptoms of vertigo 5, 3