Management of Vestibular Migraine
The first-line treatment for vestibular migraine includes lifestyle modifications, followed by preventive medications such as beta blockers (e.g., propranolol), topiramate, or candesartan when symptoms occur ≥2 days per month despite optimized acute treatment. 1
Diagnosis and Clinical Features
- Vestibular migraine has a 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 1
- Vestibular migraine should be distinguished from other causes of vertigo, including Ménière's disease, benign paroxysmal positional vertigo, and central causes such as stroke or multiple sclerosis 1
- Vestibular migraine is considered the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo 2
Acute Management
- For acute attacks, vestibular suppressants should be offered only during attacks, not for long-term use 3
- Antiemetic medications such as diphenhydramine and meclizine can help manage symptoms during acute attacks 1
- Triptans may be effective for treating concurrent headache in patients with vestibular migraine 1, 2
- Centrally acting anticholinergic drugs (scopolamine) can suppress acute vertigo attacks but have significant side effects including blurred vision, dry mouth, urinary retention, and sedation 3
- Benzodiazepines may help with acute symptoms but carry significant risk for drug dependence 3
Preventive Treatment
- Preventive treatment is indicated when symptoms occur ≥2 days per month despite optimized acute treatment 1, 4
- First-line preventive medications include:
- Second-line preventive options include:
- Calcium channel blockers (verapamil, flunarizine) 2
- Tricyclic antidepressants (amitriptyline, nortriptyline) - especially beneficial for patients with comorbid depression or sleep disturbances 4, 2
- Anticonvulsants (valproic acid, lamotrigine) - lamotrigine may be preferred if vertigo is more frequent than headaches 2
- Third-line options include CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) 1
- For chronic migraine with vestibular symptoms, onabotulinumtoxinA may be considered 3
Lifestyle Modifications
- Dietary and lifestyle modifications are recommended as first-line interventions 3, 1:
- Limit salt/sodium intake 3
- Avoid excessive caffeine, alcohol, and nicotine 3
- Eat well-balanced meals throughout the day 3
- Maintain adequate hydration 3
- Manage stress appropriately 3, 1
- Regular exercise 3
- Establish regular sleep patterns 3, 1
- Identify and manage any allergies, which may contribute to symptoms in up to 30% of patients 3
Non-Pharmacological Approaches
- Vestibular rehabilitation may be beneficial, particularly when there are complications such as loss of confidence in balance 2
- Stress reduction techniques and biobehavioral therapy can effectively manage vestibular migraine symptoms 1
- Patient education is essential to improve understanding and adherence to treatment plans 3
Follow-up and Monitoring
- The efficacy of preventive oral medications should be evaluated after 2-3 months of treatment 4
- For CGRP monoclonal antibodies, efficacy should be assessed after 3-6 months 4
- For onabotulinumtoxinA, efficacy should be evaluated after 6-9 months 4
- Long-term management should include regular follow-up to assess treatment response and adjust therapy as needed 4
Common Pitfalls to Avoid
- Overuse of vestibular suppressants, which are not recommended for long-term management 1
- Inadequate follow-up to assess treatment response 1
- Failure to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 3, 4
- Overuse of acute medications, which can lead to medication overuse headache 3, 4