What are the treatment options for vestibular migraines?

Treatment of Vestibular Migraine

For vestibular migraine, initiate prophylactic treatment with flunarizine as first-line therapy based on randomized controlled trial evidence, combined with lifestyle modifications and vestibular rehabilitation. 1, 2

Acute Attack Management

When a vestibular migraine attack occurs, treatment focuses on symptom control:

• Triptans should be tried first for acute attacks, though evidence is conflicting regarding their efficacy specifically for the vestibular symptoms 1
• Antiemetic medications (dimenhydrinate, benzodiazepines) can control nausea and vomiting during attacks 2
• Anti-vertigo medications like meclizine may be used as needed for severe vertigo, but should not be scheduled routinely to avoid impeding vestibular compensation 3, 4
• Analgesics can address headache when present 2

Critical caveat: Vestibular suppressants should be withdrawn as soon as possible and not used long-term, as they interfere with central vestibular compensation and cause drowsiness, cognitive deficits, and increased fall risk, especially in elderly patients 3

Prophylactic Treatment Algorithm

First-Line Therapy

• Flunarizine is the preferred first-line prophylactic agent based on two randomized clinical trials and favorable pharmacological properties 1

Second-Line Options (Choose Based on Comorbidities)

• Beta-blockers (propranolol or metoprolol): Preferred in patients with hypertension but contraindicated in asthma 5, 2
• Topiramate: Best choice when patients are obese 5, 2
• Valproic acid: Alternative anticonvulsant option 5, 2
• Lamotrigine: Preferred specifically when vertigo attacks are more frequent than headaches 5, 2
• Venlafaxine: SSRI option, particularly useful with comorbid anxiety 1, 2
• Tricyclic antidepressants (amitriptyline or nortriptyline): When anxiety or depression coexist 5
• Verapamil: Calcium antagonist alternative 5

Non-Pharmacological Interventions

Vestibular Rehabilitation

• Vestibular rehabilitation should be considered for all patients with vestibular migraine as it addresses loss of confidence in balance and visual dependence 2, 6
• VR has demonstrated improved headache frequency and migraine-related disability in patients with vestibular migraine 6
• Can be performed with or without direct clinician supervision 6

Lifestyle Modifications

• Dietary modifications, sleep hygiene, and trigger avoidance are recommended as foundational interventions 5, 2
• These measures should be implemented as the first step before or alongside pharmacotherapy 2

Treatment Sequence

Step 1: Implement diet and behavioral modifications immediately 2

Step 2: Initiate prophylactic medication (flunarizine first-line) to reduce attack frequency and severity 1, 2

Step 3: Provide acute attack medications (triptans, antiemetics) for breakthrough symptoms 1, 2

Step 4: Add vestibular rehabilitation therapy to address persistent balance issues and improve compensation 2, 6

Important Clinical Considerations

• Vestibular migraine can mimic Ménière's disease, making diagnosis challenging; the episodic nature and lack of hearing loss help differentiate 7
• Reassess patients within 1 month after initiating treatment to document response and adjust therapy 3
• Neurostimulating devices represent emerging options for acute treatment, though evidence remains limited 1
• The overall evidence base for vestibular migraine treatment remains low quality with heterogeneous study designs, but the recommendations above represent the best available evidence 8