What are the management options for vestibular migraine?

Management of Vestibular Migraine

Start with lifestyle modifications and dietary changes as first-line therapy, then escalate to preventive medications (beta-blockers, topiramate, or candesartan) when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Initial Assessment and Diagnosis

• Confirm the diagnosis requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 1
• Rule out central causes (stroke, multiple sclerosis) and other peripheral causes (BPPV, Ménière's disease, vestibular neuritis) through appropriate investigations 1
• Implement a headache diary to track frequency, severity, triggers, and medication use for monitoring treatment response 2
• Use validated tools like the Headache Impact Test-6 (HIT-6) to assess disease burden 2

First-Line Treatment: Lifestyle and Dietary Modifications

Begin all patients with non-pharmacological interventions before considering medications. 1

• Limit salt/sodium intake 1
• Avoid excessive caffeine, alcohol, and nicotine 1
• Eat well-balanced meals and maintain adequate hydration 1
• Establish regular sleep patterns 1
• Implement stress management techniques and regular exercise 1
• Identify and manage allergies 1
• Consider biofeedback, cognitive-behavioral therapy, and relaxation techniques as adjuncts 1

Acute Attack Management

For acute vestibular attacks, use vestibular suppressants and antiemetics, but only for short-term relief, not long-term management. 1

• Antiemetic medications (diphenhydramine, meclizine, metoclopramide) can ameliorate acute symptoms 1, 3
• Centrally acting anticholinergic drugs like scopolamine can suppress acute vertigo attacks, though with significant side effects 1
• Benzodiazepines may help with acute symptoms but carry risk of drug dependence 1
• Triptans can treat concurrent headache during attacks 1
• Critical pitfall: Avoid long-term use of vestibular suppressants 1

Preventive Pharmacological Treatment

Initiate preventive therapy when vestibular symptoms adversely affect the patient ≥2 days per month despite optimized acute treatment and lifestyle modifications. 1

First-Line Preventive Medications

• Beta-blockers (propranolol, metoprolol, atenolol): Preferred in patients with hypertension but contraindicated in asthma 1, 4
• Topiramate: Gradually titrate to 100 mg/day; particularly beneficial in obese patients due to weight loss effect 1, 4
• Candesartan: Alternative first-line option 1

Second-Line Preventive Medications

• Tricyclic antidepressants (amitriptyline, nortriptyline): Preferred when anxiety or depression is comorbid 4, 3
• Valproic acid: Alternative anticonvulsant option 4, 3
• Venlafaxine: SSRI option for patients with mood disorders 5

Third-Line Preventive Medications

• Lamotrigine: Preferred when vertigo is more frequent than headaches 4, 5
• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab): Reserved for refractory cases 1
• OnabotulinumtoxinA: May be considered for chronic migraine with vestibular symptoms 1
• Acetazolamide: May be reasonable for refractory patients, though its place in vestibular migraine is still being established 4, 5

Treatment Duration and Assessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 6
• For CGRP monoclonal antibodies, assess efficacy after 3-6 months 6
• For onabotulinumtoxinA, assess efficacy after 6-9 months 6
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 6

Vestibular Rehabilitation

• Consider vestibular rehabilitation when complications develop, such as loss of confidence in balance or visual dependence 4
• May be helpful for patients with persistent imbalance between attacks 3

Patient Education

Educate patients that vestibular migraine is a neurological disorder with a biological basis requiring multimodal treatment, not a psychological condition. 1, 2

• Emphasize that treatment adherence improves with simplified dosing schedules (once daily or less) 6
• Set realistic expectations that efficacy is rarely observed immediately and may take several weeks to months 6
• Explain that failure of one preventive treatment does not predict failure of other drug classes 6

Critical Pitfalls to Avoid

• Do not use vestibular suppressants for long-term management - they are only for acute attacks 1
• Avoid overuse of acute medications - this risks medication overuse headache 6, 1
• Do not abandon treatment prematurely - efficacy takes weeks to months to establish 6
• Ensure adequate follow-up to assess treatment response 1
• Avoid oral ergot alkaloids, opioids, and barbiturates - questionable efficacy with considerable adverse effects and dependency risk 6