What is the treatment for vestibular migraines?

Treatment for Vestibular Migraines

The most effective treatment approach for vestibular migraines includes both acute symptom management and prophylactic therapy using the same medications recommended for classic migraines, with beta-blockers, antidepressants, and anticonvulsants being first-line preventive options. 1

Acute Treatment Options

Acute attacks of vestibular migraine can be managed with:

• First-line medications:

  • NSAIDs (ibuprofen, naproxen, diclofenac) for mild to moderate attacks 1
  • Triptans + NSAIDs combination for moderate to severe attacks 1, 2
  • Antiemetic medications (dimenhydrinate) to control nausea and vertigo 2
  • Benzodiazepines for severe vertigo symptoms (short-term use only) 2

• Second-line medications:

  • CGRP antagonists (gepants) for patients who don't respond to or cannot tolerate triptans 1
  • Ditans (lasmiditan) should only be considered after failure of other treatments 1

Prophylactic Treatment

For patients with frequent or disabling vestibular migraine attacks, prophylactic therapy is essential 3:

• First-line preventive options:

  • Beta-blockers: Propranolol (80-240 mg/day) 1, 4
  • Antidepressants: Amitriptyline (30-150 mg/day) 1, 4
  • Anticonvulsants: Topiramate (100 mg/day) 1, 4
  • Calcium channel blockers: Flunarizine 4

• Second-line preventive options:

  • Valproic acid/Divalproex sodium (500-1500 mg/day) 1
  • Venlafaxine 3
  • Acetazolamide or lamotrigine for refractory cases 3

Studies have demonstrated significant improvement in both vestibular symptoms and headache with prophylactic medications. In one study, 80.9% of patients showed improvement with prophylactic therapy (p<0.001) 4. All four commonly used medications (amitriptyline, flunarizine, propranolol, and topiramate) significantly improved both vestibular symptoms (p<0.001) and headache (p<0.015) 4.

Non-Pharmacological Interventions

• Vestibular rehabilitation should be considered for all vestibular migraine patients 2
• Lifestyle modifications:
  • Regular sleep schedule
  • Consistent meal times
  • Adequate hydration
  • Regular exercise
  • Stress management techniques 1
  • Identification and avoidance of triggers through headache diary tracking 1

Important Clinical Considerations

• Vestibular migraine is often underdiagnosed and undertreated despite being a common cause of episodic vertigo 2, 5
• Symptoms may include spontaneous vertigo, triggered vertigo, positional vertigo, and head-motion dizziness 5
• Episodes of vertigo are often, but not always, accompanied by headache 5
• Auditory symptoms may mimic Ménière's disease, requiring careful differential diagnosis 5
• Patients with longer duration of vestibular symptoms may show greater benefit from prophylactic treatment 4
• Avoid opioids due to risk of dependency and rebound headaches 1
• Valproate is contraindicated during pregnancy due to teratogenicity 1
• Triptans should be used with caution in patients with cardiovascular risk factors 1

Treatment Algorithm

1. For all patients:

   • Implement lifestyle modifications and trigger avoidance
   • Consider vestibular rehabilitation

2. For acute attacks:

   • Mild to moderate: NSAIDs
   • Moderate to severe: Triptans + NSAIDs
   • Add antiemetics for nausea/vomiting

3. For patients with ≥2 disabling attacks per month:

   • Start prophylactic therapy with one of: propranolol, amitriptyline, topiramate, or flunarizine
   • Evaluate response after 2-3 months
   • If inadequate response, switch to another first-line agent or consider second-line options

4. For refractory cases:

   • Consider combination therapy or specialized medications like acetazolamide or lamotrigine
   • Refer to headache specialist for multidisciplinary management

The evidence strongly supports that proper prophylactic treatment significantly reduces the frequency, duration, and intensity of vestibular migraine attacks, improving quality of life for these patients 4, 6.