Treatment Approach for Migraine and Vertigo
For patients experiencing migraines with vertigo, the recommended first-line treatment is topiramate at a starting dose of 25mg daily, gradually increasing to 50-100mg daily, which has shown superior efficacy in reducing both vertigo intensity and migraine frequency compared to other preventive medications. 1
Understanding Migraine with Vertigo
Migraine with vertigo, also known as vestibular migraine, is characterized by:
- Episodes of vertigo associated with migraine headaches
- Vertigo symptoms that may occur independently of headaches
- Varying duration and phenomenology of vertigo symptoms
First-Line Preventive Treatment Options
Topiramate
- Dosage: Start at 25mg daily, increase by 25mg weekly to target dose of 50-100mg daily 2, 1
- Evidence: Shown to be superior to flunarizine in reducing vertigo intensity, duration, frequency, and disability 1
- Benefits: Effectively reduces both migraine frequency and vertigo symptoms
- Side effects: Paresthesia, fatigue, anorexia, nausea, taste alteration, diarrhea 3
Beta-Blockers
- Options: Propranolol (80-240 mg/day) or metoprolol 2, 4
- Contraindications: Avoid in patients with asthma, diabetes, bradycardia, or congestive heart failure 4
- Side effects: Lethargy, depression, dizziness, exercise intolerance, hypotension 4
Flunarizine
- Dosage: 10mg daily 1
- Evidence: Effective but less so than topiramate for vertigo symptoms 1
- Use as: Second-line medication when topiramate is not tolerated 2
Amitriptyline
- Dosage: Start at 10-25mg at bedtime, increase gradually to 30-150mg daily 4, 5
- Benefits: Effective for both migraine prevention and vertigo symptoms 5
- Best for: Patients with comorbid depression or anxiety 4
Acute Treatment for Vertigo Episodes
Meclizine
- Indication: FDA-approved for treatment of vertigo associated with vestibular system diseases 6
- Usage: During acute vertigo episodes
Acute Migraine Treatment
- First-line: NSAIDs (ibuprofen 400-800mg) with antiemetic if necessary 2, 4
- Second-line: Triptans (when NSAIDs are suboptimal) 2
- Caution: Avoid triptans in patients with uncontrolled hypertension, basilar or hemiplegic migraine 4
- Important: Limit acute medications to ≤10 days per month to prevent medication overuse headache 4
Treatment Algorithm
Start with preventive therapy if:
- Vertigo and/or migraines occur ≥2 days per month
- Symptoms cause significant disability
- Acute treatments are ineffective or contraindicated
Choose preventive medication based on comorbidities:
- No significant comorbidities: Topiramate (first choice)
- Hypertension: Propranolol or metoprolol
- Depression/anxiety: Amitriptyline
- Contraindication to topiramate: Flunarizine
Acute treatment plan:
- For vertigo episodes: Meclizine
- For migraine: NSAIDs first, then triptans if needed
Evaluate effectiveness after 2-3 months of preventive treatment
- If inadequate response, increase dose or switch to alternative medication
- If partial response, consider combination therapy
Non-Pharmacological Approaches
- Regular aerobic exercise (30 minutes most days)
- Consistent sleep schedule
- Adequate hydration
- Regular meals
- Stress management techniques
- Headache/vertigo diary to identify triggers 4
When to Refer to a Specialist
Refer to a neurologist or neuro-otologist if:
- Symptoms remain refractory to treatment
- Red flags present (sudden severe headache, fever, stiff neck, confusion, neurological symptoms)
- Uncertainty about diagnosis
Monitoring and Follow-up
- Follow up after 4-6 weeks of starting preventive therapy
- Assess improvement in vertigo frequency, intensity, and headache frequency
- Monitor for adverse effects
- Adjust medication dosage as needed
- Continue effective preventive therapy for 3-6 months before considering tapering
The evidence strongly supports that early intervention with appropriate preventive therapy significantly improves quality of life and prevents progression to chronic symptoms in patients with migraine and vertigo 5, 1.