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, with second-line options such as amitriptyline and flunarizine for refractory cases. 1

First-Line Treatment Options

Lifestyle Modifications

• Reducing stress
• Ensuring restful sleep
• Avoiding migraine dietary triggers
• Preventing starvation and dehydration 2
• Supplements such as vitamin B2 and magnesium 2

First-Line Medications

• Beta blockers without intrinsic sympathomimetic activity:

  • Propranolol
  • Metoprolol
  • Atenolol
  • Bisoprolol
  • Particularly beneficial in patients with hypertension but contraindicated in asthma 1, 3

• Anticonvulsants:

  • Topiramate (particularly beneficial for patients with obesity) 1, 3

• Angiotensin II receptor blockers:

  • Candesartan 1

• CGRP monoclonal antibodies:

  • Erenumab
  • Fremanezumab
  • Galcanezumab
  • Eptinezumab 1

Second-Line Treatment Options

• Calcium channel blockers:

  • Flunarizine 1, 3
  • Verapamil 3, 2

• Tricyclic antidepressants:

  • Amitriptyline (particularly beneficial for patients with depression or sleep disturbances) 1, 3, 4
  • Nortriptyline 3, 2

• Anticonvulsants:

  • Sodium valproate (strictly contraindicated in women of childbearing potential) 1, 4
  • Lamotrigine (preferred if vertigo is more frequent than headaches) 3, 5

Acute Attack Management

• Antivertiginous and antiemetic medications:

  • Diphenhydramine
  • Meclizine
  • Metoclopramide 4

• Important caveat: Vestibular suppressants should not be used as routine primary treatment due to significant risks and side effects 1

Alternative and Adjunctive Therapies

• Non-invasive neuromodulatory devices
• Biobehavioral therapy
• Acupuncture 1
• Vestibular rehabilitation (particularly helpful when there are complications such as loss of confidence in balance or visual dependence) 3

Treatment Algorithm

1. Start with lifestyle modifications and supplements

   • Dietary changes, sleep hygiene, stress management
   • Consider vitamin B2 and magnesium supplementation

2. If symptoms persist, initiate first-line medication:

   • For patients with hypertension: Beta blockers (propranolol or metoprolol)
   • For patients with obesity: Topiramate
   • Alternative: Candesartan

3. For refractory cases, consider second-line options:

   • For patients with depression or sleep disturbances: Amitriptyline
   • For patients where vertigo predominates over headache: Lamotrigine
   • Alternative: Flunarizine (where available)

4. For acute attacks:

   • Short-term use of antiemetics like meclizine or metoclopramide
   • Avoid long-term vestibular suppressant use

5. Consider CGRP monoclonal antibodies for patients not responding to conventional preventive treatments

Important Clinical Considerations

• Vestibular migraine presents with variable duration of vertigo episodes (seconds to days, typically minutes to hours) 3
• Attacks often occur independently of headaches 3
• Motion intolerance and light sensitivity are common features 1
• Hearing loss is typically mild or absent and stable over time, which helps differentiate from Menière's disease 1, 5