Vestibular Migraine: Diagnosis and Management
Diagnostic Criteria
Vestibular migraine requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, current or history of migraine, ≥1 migraine symptom during at least 50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual or other aura), and exclusion of other causes by appropriate investigations. 1, 2
Key Diagnostic Features
- Lifetime prevalence is 3.2%, accounting for up to 14% of all vertigo cases 1, 2
- Vestibular symptoms include spontaneous vertigo, triggered vertigo, positional vertigo, and head-motion dizziness 3
- Episodes often occur independently of headaches, though migrainous features should accompany at least 50% of attacks 1, 3
- Auditory symptoms may be present but hearing loss should be absent (distinguishes from Ménière's disease) 4, 3
Critical Differential Diagnoses to Exclude
- Central causes: Brainstem/cerebellar stroke, multiple sclerosis, intracranial tumors 1, 2
- Peripheral causes: Benign paroxysmal positional vertigo (BPPV), Ménière's disease, vestibular neuritis 2, 3
- Red flags suggesting central pathology include downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, or baseline nystagmus without provocative maneuvers 1
Management Algorithm
Step 1: Lifestyle Modifications (First-Line for All Patients)
Dietary and lifestyle modifications should be implemented as first-line interventions before or alongside pharmacological treatment. 2
- Limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine 2
- Eat well-balanced meals and maintain adequate hydration 2
- Establish regular sleep patterns and manage stress 2
- Regular exercise 2
- Identify and manage allergies 2
- Identify and avoid individual triggers 5, 3
Step 2: Acute Attack Management
For acute vestibular migraine attacks, use vestibular suppressants and antiemetics for symptom relief, with triptans considered for concurrent headache. 2, 3
Acute Medications
- Antiemetics: Diphenhydramine, meclizine for symptom amelioration 2
- Vestibular suppressants: Centrally acting anticholinergics like scopolamine can suppress acute vertigo attacks, though with significant side effects 2
- Benzodiazepines: May help with acute symptoms but carry risk of drug dependence 2
- Triptans: Most effective when taken early while headache is still mild, primarily for concurrent headache 2, 6, 3
Critical Pitfall
- Do not use vestibular suppressants for long-term management 2
- Limit acute medication use to ≤2 days/week to prevent medication overuse headache 7
Step 3: Preventive Treatment (When Symptoms Occur ≥2 Days/Month)
Preventive medications should be initiated when vestibular migraine adversely affects patients ≥2 days per month despite optimized acute treatment and lifestyle modifications. 2, 7
First-Line Preventive Medications
- Beta-blockers: Propranolol, metoprolol, or atenolol (preferred in hypertensive patients without asthma) 2, 5, 4
- Topiramate: Particularly useful when patients are obese 2, 5, 4
- Candesartan: First-line option 2, 7
Second-Line Preventive Medications
- Venlafaxine: Effective second-line option 8, 4
- Valproic acid: Alternative anticonvulsant 5, 8
- Lamotrigine: Preferred if vertigo is more frequent than headaches 5, 4
- Tricyclic antidepressants: Amitriptyline or nortriptyline, particularly if anxiety is present 5, 4
- Calcium antagonists: Flunarizine (based on two randomized trials, should be considered first treatment option per recent evidence) or verapamil 5, 8
Third-Line Preventive Medications
- CGRP monoclonal antibodies: Erenumab, fremanezumab, galcanezumab, eptinezumab 2
- OnabotulinumtoxinA: May be considered for chronic migraine with vestibular symptoms 2
- Acetazolamide: For refractory patients, though its place in vestibular migraine is still being established 5, 4
Step 4: Treatment Duration and Assessment
Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose. 2
- For oral preventives: Evaluate after 2-3 months, consider pausing after 6-12 months of successful control 2
- For CGRP monoclonal antibodies: Assess after 3-6 months 2
- For onabotulinumtoxinA: Assess after 6-9 months 2
- Efficacy is rarely observed immediately and may take several weeks to months 2
- Failure of one preventive treatment does not predict failure of other drug classes 2
Step 5: Non-Pharmacological Adjunctive Therapy
Vestibular rehabilitation should be considered as prophylactic treatment, particularly when complications such as loss of confidence in balance or visual dependence develop. 5, 8
- Biobehavioral therapy and stress reduction techniques can be effective 2
- Patient education is essential to improve understanding and adherence 2
Critical Pitfalls to Avoid
- Never use oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 2, 6
- Avoid overuse of acute medications (>2 days/week) which risks medication overuse headache 2, 7
- Do not abandon treatment prematurely as efficacy takes weeks to months to establish 2
- Recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 2, 3
- Ensure adequate follow-up to assess treatment response 2
- Failure to respond to conservative management should raise concern that the underlying diagnosis may not be vestibular migraine 1
Medication Selection Strategy
Choose preventive medication based on side effect profile and patient comorbidities:
- Hypertension present, no asthma: Beta-blockers (propranolol, metoprolol) 5
- Obesity: Topiramate 5
- Anxiety or depression: Tricyclic antidepressants (amitriptyline, nortriptyline) or SSRIs 5
- Vertigo more frequent than headaches: Lamotrigine 5
- Refractory cases: Consider acetazolamide or lamotrigine 4
Set realistic expectations that simplified dosing schedules improve adherence and that treatment effects develop gradually over weeks to months 2.