What is the best treatment approach for vestibular migraine?

Treatment Approach for Vestibular Migraine

Beta blockers (propranolol, metoprolol), topiramate, or candesartan should be used as first-line preventive medications for vestibular migraine. 1

Understanding Vestibular Migraine

Vestibular migraine is considered the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo 2. It presents with episodes of vertigo, disequilibrium, or imbalance that can last from seconds to days, though typically minutes to hours, and often occurs independently of headaches 2.

Treatment Algorithm

Acute Attack Management

1. First-line medications:

   • NSAIDs with antiemetics if necessary 1
   • Antivertiginous medications (dimenhydrinate, meclizine) 3
   • Antiemetics (metoclopramide) 3

2. Second-line medications (if first-line fails after three consecutive attacks):

   • Triptans 1, 4

3. Third-line medications (if all triptans fail):

   • Ditans or gepants 1

Preventive Treatment

Initiate preventive treatment when patients are adversely affected by migraine on ≥2 days per month despite optimized acute treatment 1.

1. First-line preventive medications:

   • Beta blockers without intrinsic sympathomimetic activity (propranolol, metoprolol, atenolol, bisoprolol) 1
   • Topiramate 1
   • Candesartan 1

2. Second-line preventive medications:

   • Flunarizine 1
   • Amitriptyline 1
   • Sodium valproate (in men only, contraindicated in women of childbearing potential) 1

3. Third-line preventive medications:

   • CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1

4. Alternative options for refractory cases:

   • Lamotrigine (especially if vertigo is more frequent than headaches) 2
   • Venlafaxine 5
   • Acetazolamide (though its place in vestibular migraine is still being established) 2, 5

Adjunctive Non-Pharmacological Approaches

1. Vestibular rehabilitation:

   • Should be considered for all vestibular migraine patients 4
   • Particularly beneficial when there are complications such as loss of confidence in balance or visual dependence 2

2. Behavioral interventions:

   • Biobehavioral therapy 1
   • Relaxation techniques 3
   • Stress management 3
   • Regular exercise (40 minutes three times a week) 1

3. Acupuncture:

   • May be considered as an adjunct to medication or as stand-alone treatment when medication is contraindicated 1

4. Neuromodulatory devices:

   • Can be used as adjuncts to acute and preventive medications 1

Important Clinical Considerations

• Medication overuse: Monitor and limit as-needed medication use to prevent medication overuse headache 1

• Comorbidities: Consider and appropriately treat comorbid conditions that may influence treatment choice 1

  • For patients with hypertension but without asthma, beta blockers are preferred 2
  • For obese patients, topiramate may be preferred 2
  • For patients with anxiety, tricyclic antidepressants, SSRIs, or benzodiazepines like clonazepam may be recommended 2

• Special populations:

  • In older patients, monitor cardiovascular risk factors if triptans are used 1
  • For pregnant women, metoclopramide can be used under supervision 6

• Patient education:

  • Explain that vestibular migraine is a neurological disorder with a biological basis 1
  • Set realistic expectations as prognosis appears to be less favorable for vestibular migraine than for migraine headaches 3

Treatment Pitfalls to Avoid

1. Prolonged use of vestibular suppressants: Should be used for short-term symptomatic relief only, as long-term use can delay vestibular compensation 6

2. Overreliance on unproven therapies: Little to no evidence exists for physical therapy (except vestibular rehabilitation), spinal manipulation, and dietary approaches 1

3. Misdiagnosis: Ensure proper diagnosis by ruling out other causes of vertigo, particularly Meniere's disease which can be confused with vestibular migraine 5

4. Inadequate follow-up: Vestibular migraine often requires ongoing management and adjustment of preventive strategies 1