What is the treatment for vestibular migraine?

Treatment of Vestibular Migraine

The first-line treatment for vestibular migraine includes lifestyle modifications, followed by preventive medications such as beta blockers (atenolol, bisoprolol, metoprolol, or propranolol), topiramate, or candesartan when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Understanding Vestibular Migraine

Vestibular migraine is a common cause of episodic vertigo with the following characteristics:

• Lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 1
• 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 1

Treatment Algorithm

Step 1: Non-pharmacological Approaches (First-line)

• Lifestyle and dietary modifications:
  • Stress reduction techniques
  • Regular sleep schedule
  • Avoidance of migraine dietary triggers
  • Prevention of dehydration and starvation 2
• Supplements:
  • Vitamin B2 and magnesium 2
• Consider non-invasive options:
  • Neuromodulatory devices
  • Biobehavioral therapy
  • Acupuncture 1

Step 2: Acute Treatment for Attacks

• Antiemetic medications can help ameliorate symptoms:
  • Diphenhydramine
  • Meclizine
  • Metoclopramide 3
• For patients with concurrent headache:
  • NSAIDs with antiemetics if needed
  • Triptans (if NSAIDs ineffective) 1

Step 3: Preventive Pharmacological Treatment

Indicated when attacks are frequent (≥2 days per month) despite optimized acute treatment 1

First-line preventive medications:

• Beta blockers without intrinsic sympathomimetic activity:
  • Atenolol
  • Bisoprolol
  • Metoprolol
  • Propranolol 1
• Topiramate 1, 3
• Candesartan 1

Second-line preventive medications:

• Flunarizine
• Amitriptyline
• Sodium valproate (contraindicated in women of childbearing potential) 1, 3

Third-line preventive medications:

• CGRP monoclonal antibodies:
  • Erenumab
  • Fremanezumab
  • Galcanezumab
  • Eptinezumab 1

Special Considerations

Differential Diagnosis

• Important to distinguish vestibular migraine from other causes of vertigo:
  • Benign paroxysmal positional vertigo (BPPV)
  • Ménière's disease
  • Vestibular neuritis
  • Central causes (stroke, multiple sclerosis) 1

Diagnostic Challenges

• Vestibular migraine is often underdiagnosed despite published diagnostic criteria 4
• About one-third of patients present with monosymptomatic attacks of vertigo or dizziness without headache 5
• Vestibular migraine may be difficult to distinguish from Ménière's disease 5

Treatment Limitations

• Evidence base for vestibular migraine treatment is of low quality 6
• Few randomized controlled trials specifically for vestibular migraine 4
• Current recommendations are largely borrowed from migraine treatment guidelines 3
• The PROVEMIG trial (testing metoprolol vs. placebo) is ongoing 4

Prognosis

• Limited data suggest prognosis may be less favorable for vestibular migraine than for migraine headaches 3
• Symptoms may begin at any age, with highest prevalence in young adults and between ages 60-70 5

Common Pitfalls to Avoid

• Misdiagnosing vestibular migraine as Ménière's disease or other vestibular disorders 5
• Overuse of vestibular suppressant medications, which are not recommended for long-term management 1
• Failure to recognize vestibular migraine in patients with vertigo but without headache 5
• Inadequate follow-up to assess treatment response 1