What are the treatment options for vestibular migraines?

Treatment of Vestibular Migraine

First-line treatment for vestibular migraine consists of lifestyle modifications followed by preventive medications—specifically beta blockers (propranolol, metoprolol, or atenolol), topiramate, or candesartan—when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Initial Management Approach

Lifestyle Modifications (First-Line)

Start all patients with dietary and lifestyle interventions before considering pharmacological therapy 1:

• Limit salt/sodium intake to reduce vestibular symptoms 1
• Avoid excessive caffeine, alcohol, and nicotine as these are common triggers 1
• Maintain regular sleep patterns with consistent sleep-wake times 1
• Ensure adequate hydration and eat well-balanced meals 1
• Implement stress management techniques including biobehavioral therapy 1
• Regular exercise as tolerated 1
• Identify and manage allergies that may exacerbate symptoms 1

Many patients with infrequent, tolerable attacks do not require pharmacological treatment beyond these measures 2.

Acute Attack Management

Symptomatic Relief

For acute vestibular episodes, use antiemetic medications 1, 2:

• Diphenhydramine for nausea and vertigo 1, 2
• Meclizine for acute vestibular symptoms 1, 2
• Metoclopramide for nausea and gastric motility 2

Important caveat: Vestibular suppressants (including benzodiazepines and anticholinergics like scopolamine) should only be used for short-term management of severe acute symptoms, not for long-term treatment 1. While benzodiazepines may help acute symptoms, they carry significant risk of drug dependence 1.

Migraine-Specific Acute Treatment

Triptans can be used to treat concurrent headache during vestibular migraine attacks 1, 3. However, triptans are unlikely to be very effective for the vestibular symptoms themselves 4.

Preventive Pharmacological Treatment

Initiate preventive therapy when attacks occur ≥2 days per month despite optimized acute treatment and lifestyle modifications 1.

First-Line Preventive Medications

Beta Blockers (preferred in patients with hypertension, avoid in asthma) 1, 4:

• Propranolol 4, 2, 3
• Metoprolol 4, 2
• Atenolol 1

Topiramate (preferred in obese patients) 1, 4, 2, 3

Candesartan 1

Second-Line Options Based on Comorbidities

For patients with anxiety or depression 4:

• Amitriptyline (tricyclic antidepressant) 4, 2, 3
• Nortriptyline (tricyclic antidepressant) 4
• Venlafaxine (SSRI) 3

For patients with frequent vertigo more than headaches 4:

• Lamotrigine 4, 3

Other options 4, 2:

• Valproic acid 4, 2
• Verapamil (calcium antagonist) 4
• Flunarizine (calcium antagonist) 4, 2

Third-Line Preventive Medications

CGRP monoclonal antibodies for refractory cases 1:

• Erenumab
• Fremanezumab
• Galcanezumab
• Eptinezumab

For refractory patients, consider 3:

• Acetazolamide (though its place in vestibular migraine is still being established) 4, 3
• Lamotrigine 3

OnabotulinumtoxinA may be considered for chronic migraine with vestibular symptoms 1

Treatment Duration and Monitoring

Assessment Timeline

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1
• For CGRP monoclonal antibodies, assess after 3-6 months 1
• For onabotulinumtoxinA, assess after 6-9 months 1

Treatment Duration

Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1. Efficacy is rarely observed immediately and may take several weeks to months 1.

Non-Pharmacological Adjunctive Therapy

Vestibular rehabilitation may be useful when complications develop, such as loss of confidence in balance or visual dependence 4. This can be combined with pharmacological approaches 2.

Critical Pitfalls to Avoid

Avoid these medications due to questionable efficacy with considerable adverse effects and dependency risk 1:

• Oral ergot alkaloids
• Opioids
• Barbiturates

Do not overuse acute medications, as this risks medication overuse headache 1.

Do not abandon treatment prematurely—efficacy takes weeks to months to establish 1. Failure of one preventive treatment does not predict failure of other drug classes 1.

Avoid long-term use of vestibular suppressants (benzodiazepines, anticholinergics), which are only appropriate for short-term acute symptom management 1.

Monitor patients regularly for development of latent audiovestibular end-organ disease, as vertigo itself may trigger migraine and patients may have coexisting vestibular pathology 5.