What are the treatment options for vestibular migraines?

Treatment Options for Vestibular Migraine

The first-line treatment for vestibular migraine includes lifestyle modifications, beta blockers (propranolol or metoprolol), topiramate, or candesartan, followed by second-line options such as amitriptyline and flunarizine if first-line treatments fail. 1

Diagnosis Considerations

Before initiating treatment, it's important to properly identify vestibular migraine, which can mimic Ménière's disease:

• Vestibular migraine may present with short (<15 minutes) or prolonged (>24 hours) periods of vertigo
• Visual auras may occur before, during, or after attacks
• Hearing loss is typically mild or absent and stable over time (unlike Ménière's disease)
• Motion intolerance and light sensitivity are common features 1

Treatment Algorithm

First-Line Treatments

1. Non-pharmacological approaches:

   • Lifestyle and dietary modifications (reducing stress, ensuring restful sleep, avoiding migraine dietary triggers, preventing dehydration) 2
   • Supplements: vitamin B2 and magnesium 2

2. First-line medications:

   • Beta blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, or bisoprolol)
   • Topiramate (particularly beneficial for patients with obesity)
   • Candesartan 1

Second-Line Treatments

If first-line treatments fail, consider:

• Flunarizine
• Amitriptyline (particularly beneficial for patients with depression or sleep disturbances)
• Sodium valproate (contraindicated in women of childbearing potential) 1

Third-Line Treatments

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1

Acute Attack Management

For acute vestibular migraine attacks:

• Antiemetic drugs (diphenhydramine, meclizine, metoclopramide) 3
• Triptans may be effective for acute attacks 4

Special Considerations

Treatment Selection Based on Patient Characteristics

• Hypertension (without asthma): Beta blockers (propranolol, metoprolol)
• Obesity: Topiramate
• Vertigo more frequent than headaches: Lamotrigine
• Anxiety: Tricyclic antidepressants (amitriptyline, nortriptyline), SSRIs, or benzodiazepines (clonazepam) 5

Adjunctive Therapies

• Vestibular rehabilitation may be beneficial, especially for patients with loss of confidence in balance or visual dependence 5
• Non-invasive neuromodulatory devices, biobehavioural therapy, and acupuncture can be considered as adjuncts to medication or as stand-alone treatments when medications are contraindicated 1

Follow-up and Monitoring

• Reassess treatment efficacy after 1-3 months
• Consider switching medications if inadequate response
• For chronic vestibular migraine, more aggressive preventive therapy may be needed

Pitfalls and Caveats

1. Avoid overuse of acute medications to prevent medication overuse headache
2. Be aware that vestibular migraine can mimic Ménière's disease, but hearing loss is typically mild or absent in vestibular migraine
3. Sodium valproate is strictly contraindicated in women of childbearing potential 1
4. Treatment response may be less favorable for vestibular migraine than for migraine headaches 3
5. Vestibular suppressants should not be used as routine primary treatment due to significant risks and side effects 6

By following this structured approach to treatment, most patients with vestibular migraine can achieve significant symptom improvement and better quality of life.