What are the management options for vestibular migraines?

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

• Vestibular symptoms include spontaneous vertigo, triggered vertigo, positional vertigo, head-motion dizziness, or disequilibrium 3
• Migraine features during attacks may include headache, photophobia, phonophobia, osmophobia, or visual aura 3
• Lifetime prevalence is 3.2%, accounting for up to 14% of all vertigo cases 1, 2
• Episodes often occur independently of headaches, making diagnosis challenging 4

Critical Differential Diagnoses to Exclude

• Benign paroxysmal positional vertigo (BPPV): Distinguished by positional triggers and characteristic nystagmus on Dix-Hallpike maneuver 1
• Central causes: Brainstem/cerebellar stroke, multiple sclerosis, intracranial tumors—look for focal neurologic deficits, dysarthria, dysmetria, dysphagia, or Horner's syndrome 1, 5
• Ménière's disease: Characterized by hearing loss, which should be absent in vestibular migraine 6, 3
• Vestibular neuritis: Presents with baseline nystagmus without provocative maneuvers 1

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Management Algorithm

First-Line: Lifestyle Modifications

Begin with dietary and lifestyle modifications including limiting salt/sodium intake, avoiding excessive caffeine, alcohol, and nicotine, eating well-balanced meals, maintaining adequate hydration, managing stress, regular exercise, establishing regular sleep patterns, and identifying/managing allergies. 2

• These interventions are recommended as first-line before pharmacological treatment 2
• Patient education is essential to improve understanding and adherence 2

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Acute Attack Treatment

Pharmacological Options for Acute Episodes

• Triptans can be used to treat concurrent headache, most effective when taken early while headache is still mild 2, 7, 8
• Vestibular suppressants (e.g., meclizine, diphenhydramine) help ameliorate acute symptoms but are not recommended for long-term use 2, 4
• Antiemetic medications (e.g., diphenhydramine, meclizine) for nausea during attacks 2
• Benzodiazepines (e.g., scopolamine) may help with acute symptoms but carry risk of drug dependence and significant side effects 2, 4

Critical Pitfall

• Limit acute medication use to ≤2 days per week to prevent medication overuse headache 2, 5

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Preventive Treatment

Preventive medications should be initiated when symptoms occur ≥2 days per month despite optimized acute treatment. 2, 5

First-Line Preventive Medications

Beta-blockers (propranolol, metoprolol, atenolol), topiramate, or candesartan are first-line preventive options. 2, 7, 5

• Beta-blockers: Preferred in patients with hypertension but contraindicated in asthma 4
• Topiramate: Preferred when patients are obese 4
• Candesartan: Alternative first-line option 2

Second-Line Preventive Medications

• Tricyclic antidepressants (amitriptyline, nortriptyline): Preferred if patients have comorbid anxiety 4, 6
• Venlafaxine: SSRI option for patients with anxiety 4, 6
• Valproic acid: Alternative anticonvulsant 4, 6
• Lamotrigine: Preferred if vertigo is more frequent than headaches 4

Third-Line Preventive Medications

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) can be used as third-line options 2
• OnabotulinumtoxinA may be considered for chronic migraine with vestibular symptoms 2

Treatment Duration and Assessment

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

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Non-Pharmacological Approaches

Vestibular Rehabilitation

• Vestibular rehabilitation is useful when there are complications such as loss of confidence in balance or visual dependence 4, 9
• May be helpful as adjunctive therapy alongside pharmacological prevention 6

Behavioral Interventions

• Stress reduction techniques, regular sleep schedule, and biobehavioral therapy can be effective 2
• Identifying and avoiding migraine triggers is essential 4

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Critical Pitfalls to Avoid

• Do NOT use oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 2
• Avoid overuse of vestibular suppressant medications for long-term management 2
• Do NOT abandon treatment prematurely—efficacy takes weeks to months to establish 2
• Recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 2
• Failure to respond to conservative management should raise concern that the underlying diagnosis may not be vestibular migraine 1
• Set realistic expectations that efficacy is rarely observed immediately and may take several weeks to months 2
• Emphasize that failure of one preventive treatment does not predict failure of other drug classes 2