What is the treatment for vertiginous migraine?

Treatment of Vertiginous Migraine (Vestibular Migraine)

For acute attacks of vestibular migraine, use triptans as first-line therapy when headache is present, and for prophylaxis in patients with frequent or disabling attacks, flunarizine should be considered the first-choice preventive medication based on randomized trial evidence. 1

Acute Attack Treatment

First-Line Acute Therapy

• Triptans are the primary migraine-specific medication for acute vestibular migraine attacks, particularly when headache accompanies the vertigo. 1, 2
• Begin with oral sumatriptan 50-100 mg at attack onset, which can be repeated after 2 hours if symptoms persist, with a maximum daily dose of 200 mg. 3
• Alternative triptans include rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg if sumatriptan is ineffective or poorly tolerated. 4
• Treat early in the attack when symptoms are still mild to maximize efficacy, as delayed treatment reduces response rates. 5

Adjunctive Acute Therapy

• Add vestibular suppressants during acute attacks to manage vertigo symptoms directly. 2, 6
• Consider antiemetics such as metoclopramide 10 mg or prochlorperazine 10 mg for nausea, which also provide synergistic analgesia. 5, 4
• NSAIDs (ibuprofen, naproxen sodium, or diclofenac potassium) can be used for mild-to-moderate attacks or combined with triptans to prevent symptom relapse. 5

Important Acute Treatment Caveat

• Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache, which affects both the headache and vestibular components. 4, 7
• Many vestibular migraine patients present with monosymptomatic vertigo attacks without headache, making diagnosis challenging but not precluding triptan use. 8

Prophylactic Treatment

First-Line Preventive Therapy

• Flunarizine is the first-choice preventive medication based on two randomized clinical trials demonstrating efficacy specifically for vestibular migraine. 1
• Initiate preventive therapy when attacks occur more than twice weekly, cause significant disability, or when acute medication use becomes excessive. 5, 4

Second-Line Preventive Options

• Propranolol is a well-established second-line option with evidence from general migraine prevention that extends to vestibular migraine. 1, 2
• Venlafaxine (SNRI) is effective for patients who cannot tolerate beta-blockers or calcium channel blockers. 1, 2
• Topiramate provides an alternative for patients requiring weight loss or those with comorbid epilepsy. 1, 2
• Amitriptyline can be considered, particularly for patients with comorbid anxiety or sleep disturbance. 2

Refractory Cases

• For patients failing first- and second-line preventive treatments, consider acetazolamide or lamotrigine as third-line options. 2
• Valproic acid may be used but is absolutely contraindicated in women of childbearing potential. 5

Non-Pharmacological Treatment

Vestibular Rehabilitation

• Vestibular rehabilitation therapy is a sound prophylactic treatment option that should be incorporated into the management plan, particularly for patients with persistent disequilibrium between attacks. 1, 2
• This approach addresses both the acute vestibular dysfunction and helps prevent future attacks through habituation and compensation mechanisms. 1

Behavioral Interventions

• Relaxation training, thermal biofeedback combined with relaxation, and cognitive-behavioral therapy are effective adjuncts that can be combined with preventive drug therapy. 4

Critical Diagnostic Considerations

Distinguishing Features

• Vestibular migraine attacks last from seconds to days, with considerable variation in duration being characteristic. 8
• Hearing loss should be absent in vestibular migraine; its presence suggests Menière's disease instead. 2
• Symptoms typically worsen with activity and head movements, encompassing vertigo, disequilibrium, or imbalance. 2
• During acute attacks, central spontaneous or positional nystagmus may be present, and less commonly, unilateral vestibular hypofunction. 6

Common Pitfalls to Avoid

• Do not dismiss the diagnosis when headache is absent during vertigo attacks—approximately one-third of patients present with monosymptomatic vertigo without concurrent headache. 8
• Avoid confusing vestibular migraine with Menière's disease; the key differentiator is the absence of hearing loss in vestibular migraine. 2
• Do not allow patients to increase acute medication frequency in response to persistent symptoms, as this creates medication-overuse headache; instead, escalate to preventive therapy. 7

Treatment Efficacy Timeline

• Preventive therapy requires 2-3 months for oral agents to demonstrate full efficacy, so counsel patients about this timeline to maintain adherence. 7
• The safety of treating more than 4 headaches in a 30-day period with triptans has not been established, reinforcing the need for preventive therapy in frequent attackers. 3