What are the management options for vestibular migraines?

Management of Vestibular Migraines

The management of vestibular migraines should focus on both acute symptom control and preventive therapy, with prophylactic medications being the mainstay of treatment. 1

Diagnosis Considerations

Before initiating treatment, it's important to ensure accurate diagnosis of vestibular migraine (VM), which is characterized by:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours
• Current or history of migraine according to International Headache Society Criteria
• ≥1 migraine symptoms during at least 50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual or other aura)
• Other causes ruled out by appropriate investigations 2

VM must be distinguished from Ménière's disease, which may present with similar symptoms but typically includes fluctuating hearing loss 2.

Acute Management

For acute vestibular migraine attacks:

1. Vestibular suppressants:

   • Meclizine is FDA-approved for vertigo associated with vestibular system diseases 3
   • Should be used only during acute attacks, not chronically 2
   • Other options include benzodiazepines (with caution due to dependence risk) and anticholinergics like scopolamine 2

2. Antimigraine medications:

   • Triptans may be effective for acute attacks 4
   • NSAIDs (ibuprofen 400-800mg, naproxen sodium 500-550mg) 5

Caution: Vestibular suppressants should be limited to short-term use during attacks only to prevent medication dependence and adaptation issues 2.

Preventive Treatment

For patients with frequent or disabling attacks, preventive therapy is essential:

1. First-line options:

   • Beta-blockers: Propranolol (80-240 mg/day) or metoprolol 5, 1
   • Anticonvulsants: Topiramate (100 mg/day) 5, 1
   • Tricyclic antidepressants: Amitriptyline (30-150 mg/day) or nortriptyline 5, 1, 6
   • Calcium channel blockers: Verapamil or flunarizine 1, 6

2. Second-line options:

   • Lamotrigine (preferred if vertigo is more frequent than headaches) 1
   • Valproic acid (500-1500 mg/day) 5, 1
   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) 5
   • Acetazolamide (particularly in cases with features of episodic ataxia) 1, 4

3. Medication selection algorithm:

   • With hypertension (without asthma): Beta-blockers
   • With obesity: Topiramate
   • With anxiety: Tricyclic antidepressants or benzodiazepines
   • With vertigo > headaches: Lamotrigine
   • With sleep disturbances: Amitriptyline

Lifestyle Modifications and Non-Pharmacological Approaches

These should be implemented alongside pharmacological treatments:

• Dietary modifications:

  • Limit salt/sodium intake 2
  • Avoid excessive caffeine, alcohol, and nicotine 2
  • Identify and avoid migraine dietary triggers 6
  • Eat well-balanced meals throughout the day 2
  • Stay hydrated 2, 6

• Lifestyle changes:

  • Stress management 2, 6
  • Regular exercise 2, 5
  • Adequate sleep and consistent sleep schedule 2, 5, 6
  • Identify and manage any allergies (may contribute to symptoms in up to 30% of patients) 2

• Supplements:

  • Magnesium (400-600 mg daily) 5, 6
  • Vitamin B2 (riboflavin) 5, 6
  • Coenzyme Q10 5

• Vestibular rehabilitation:

  • May be helpful for patients with loss of confidence in balance or visual dependence 1
  • Particularly useful when there are complications from vestibular migraine 1

Monitoring and Follow-up

• Use a headache/vertigo diary to track frequency, severity, and medication use 5
• Assess effectiveness of preventive treatment after 6-8 weeks at therapeutic doses 5
• Monitor for development of latent audiovestibular end-organ disease 7

Special Considerations

• Women with migraine with aura should avoid combined hormonal contraceptives with estrogens due to increased stroke risk 5
• Topiramate and valproate have teratogenic effects; effective birth control methods and folate supplementation are advised 5
• Consider specialist referral if two or more preventive medication trials fail, diagnosis uncertainty exists, or complex comorbidities are present 5

By implementing this comprehensive management approach, most patients with vestibular migraine can achieve significant symptom control and improved quality of life.