How can vestibular migraines be prevented?

Prevention of Vestibular Migraine

Begin preventive treatment with lifestyle modifications as first-line therapy, followed by beta blockers (atenolol, metoprolol, or propranolol), topiramate, or candesartan when vestibular symptoms occur ≥2 days per month despite optimized acute treatment. 1

When to Initiate Preventive Therapy

• Consider preventive treatment in patients adversely affected by vestibular migraine on ≥2 days per month despite optimized acute treatment 2, 1
• Many patients with infrequent, tolerable attacks do not require pharmacological prevention and can be managed with explanation, reassurance, and lifestyle modifications alone 3

First-Line Preventive Strategies

Lifestyle and Dietary Modifications

These should be implemented before or alongside pharmacological therapy:

• Limit salt/sodium intake to reduce vestibular symptom burden 1
• Avoid excessive caffeine, alcohol, and nicotine, which can trigger attacks 1
• Eat well-balanced meals and maintain adequate hydration 1
• Establish regular sleep patterns, as sleep disruption is a common trigger 1
• Implement stress management techniques and regular exercise 1
• Identify and manage allergies that may exacerbate symptoms 1
• Identify individual triggers through a symptom diary and systematically avoid them 4

First-Line Pharmacological Prevention

When lifestyle modifications are insufficient, initiate one of these medications:

• Beta blockers: Propranolol, metoprolol, atenolol, or bisoprolol are preferred first-line agents 2, 1, 4

  • Particularly appropriate for patients with comorbid hypertension 4
  • Contraindicated in patients with asthma 4

• Topiramate: First-line option, especially beneficial in obese patients 2, 4

• Candesartan: First-line angiotensin receptor blocker option 2, 1

Second-Line Preventive Medications

If first-line agents fail or are contraindicated, consider:

• Flunarizine: Calcium channel blocker effective for vestibular migraine prevention 2, 4

• Amitriptyline or nortriptyline: Tricyclic antidepressants, particularly useful when anxiety or depression coexist 2, 4

• Valproic acid: Anticonvulsant option (use in men; avoid in women of childbearing potential) 2, 4

• Lamotrigine: Preferred when vertigo episodes are more frequent than headaches 4, 5

• Venlafaxine: SSRI option for patients with comorbid anxiety or depression 4, 5

Third-Line and Refractory Cases

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be considered as third-line medications when first- and second-line agents have failed 2, 1

• OnabotulinumtoxinA may be considered for chronic migraine with vestibular symptoms 1

• Acetazolamide may be reasonable for refractory patients, though its role remains to be fully established 4, 5

Non-Pharmacological Preventive Approaches

• Biobehavioral therapy including relaxation techniques, stress management, and biofeedback can be as effective as pharmacological approaches and should be combined with medication 2, 3

• Vestibular rehabilitation is useful when complications develop, such as loss of confidence in balance or visual dependence 4

• Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medication is contraindicated 2

• Acupuncture has some supporting evidence, though not superior to sham acupuncture 2

Treatment Duration and Assessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1

• For CGRP monoclonal antibodies, assess efficacy after 3-6 months 1

• For onabotulinumtoxinA, assess efficacy after 6-9 months 1

• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1

• Set realistic expectations that efficacy is rarely immediate and may take several weeks to months 1

Critical Pitfalls to Avoid

• Do not overuse vestibular suppressant medications (meclizine, diphenhydramine) for long-term management; these are only for acute attacks 1

• Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 1

• Do not abandon treatment prematurely; efficacy takes weeks to months to establish 1

• Avoid overuse of acute medications, which risks medication overuse headache 1

• Do not assume failure of one preventive drug class predicts failure of others; different mechanisms may work for individual patients 1

• Ensure adequate follow-up to assess treatment response and adjust therapy accordingly 1