What are the management options for vestibular migraine?

Management of Vestibular Migraine

For patients with vestibular migraine, a comprehensive treatment approach should include both non-pharmacological interventions and pharmacological options, with prophylactic medications being the mainstay of management, particularly beta-blockers, antiseizure medications, and tricyclic antidepressants. 1

Diagnosis and Clinical Features

Vestibular migraine is one of the most common causes of vertigo, accounting for up to 14% of vertigo cases with a lifetime prevalence of 3.2% 2. Diagnostic criteria include:

• ≥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

It's important to differentiate vestibular migraine from other causes of vertigo, particularly benign paroxysmal positional vertigo (BPPV) and central neurological disorders.

Treatment Approach

Non-Pharmacological Management

These interventions should be implemented for all vestibular migraine patients:

• Lifestyle modifications:

  • Regular sleep schedule
  • Regular meals and adequate hydration
  • Moderate aerobic exercise
  • Stress management techniques 1

• Behavioral interventions:

  • Relaxation training
  • Thermal biofeedback combined with relaxation training
  • Cognitive behavioral therapy
  • Mindfulness-based treatment 1

• Vestibular rehabilitation should be considered for all patients with vestibular migraine, especially those with complications such as loss of confidence in balance or visual dependence 3, 4

Acute Attack Management

For symptomatic relief during vestibular migraine attacks:

• Antiemetic medications:

  • Dimenhydrinate
  • Benzodiazepines (short-term use)
  • Metoclopramide 3, 5

• Analgesics:

  • Triptans may be effective for some patients during acute attacks 3, 6

Prophylactic Treatment

Prophylactic medication is the mainstay of vestibular migraine management for patients with frequent or disabling attacks:

1. First-line options:

   • Beta-blockers: Propranolol (80-240 mg/day) or metoprolol 1, 4
   • Antiseizure medications: Topiramate (100 mg/day) or valproic acid (500-1500 mg/day) 1, 5
   • Tricyclic antidepressants: Amitriptyline (30-150 mg/day) 1, 6

2. Alternative options:

   • Calcium channel blockers: Flunarizine or verapamil 1, 4
   • SNRIs: Venlafaxine (75-150 mg/day) 1, 6
   • Angiotensin receptor blockers: Candesartan (8-32 mg daily) 1

3. For refractory cases:

   • Lamotrigine (particularly if vertigo is more frequent than headaches) 1, 4
   • Acetazolamide (though its place in vestibular migraine treatment is still being established) 1, 6

Treatment Initiation and Monitoring

• Start with a low dose and titrate slowly
• Allow 6-8 weeks at therapeutic dose to evaluate efficacy
• Target goal: 50% reduction in attack frequency
• Regular follow-up appointments to monitor progress and adjust treatment as needed 1

Special Considerations

• Medication overuse headache: Limit use of simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month 1

• Pregnancy considerations: Avoid valproate and topiramate due to teratogenic effects 1

• Women with migraine with aura: Avoid combined hormonal contraceptives with estrogens due to increased stroke risk 1

• Supplements: Consider magnesium (400-600 mg daily), coenzyme Q10, or riboflavin (400 mg daily) as adjunctive treatments 1

Treatment Failure and Combination Therapy

If the first preventive medication fails after an adequate trial (6-8 weeks):

1. Switch to another first-line agent
2. If multiple first-line agents fail, consider combination therapy
3. Consider newer CGRP-targeted therapies 1

The prognosis for vestibular migraine appears to be less favorable than for migraine headaches, emphasizing the importance of appropriate management 5.