What are the management options for vestibular migraine?

Management of Vestibular Migraine

Begin with lifestyle modifications and dietary changes as first-line therapy, then escalate to preventive pharmacotherapy with beta-blockers (propranolol, metoprolol, atenolol), topiramate, or candesartan when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Initial Assessment and Diagnosis Confirmation

• Confirm the diagnosis meets criteria of ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, after excluding central causes (stroke, multiple sclerosis) and other peripheral causes (BPPV, Ménière's disease, vestibular neuritis) through appropriate investigations 1
• Implement a headache diary to track frequency, severity, triggers, and medication use to monitor treatment response and identify patterns 1
• Rule out medication overuse headache if acute medications are being used frequently, as this will prevent response to preventive therapy 2

Lifestyle Modifications (First-Line for All Patients)

The American Academy of Otolaryngology-Head and Neck Surgery recommends dietary and lifestyle modifications as the initial intervention before pharmacotherapy. 1

• Limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine 1
• Eat well-balanced meals and maintain adequate hydration 1
• Establish regular sleep patterns and manage stress through relaxation techniques 1
• Identify and manage allergies that may trigger symptoms 1
• Regular exercise has proven efficacy comparable to pharmacological approaches 3

Acute Attack Management

• Use antiemetic medications (diphenhydramine, meclizine, metoclopramide) to ameliorate symptoms during acute attacks 1, 4
• Triptans can be used to treat concurrent headache in patients with vestibular migraine 1, 5
• Vestibular suppressants (centrally acting anticholinergics like scopolamine, benzodiazepines) may help acute symptoms but should not be used for long-term management due to significant side effects and risk of drug dependence 1
• Limit acute medication use to no more than twice weekly to prevent medication overuse headache 2

Preventive Pharmacotherapy Algorithm

First-Line Preventive Medications

Beta-blockers without intrinsic sympathomimetic activity are the preferred first-line agents: 1, 3

• Propranolol, metoprolol, atenolol, or bisoprolol - particularly beneficial in patients with comorbid hypertension, but contraindicated in asthma 1, 6
• Topiramate (gradually titrate to 100 mg/day) - especially beneficial in obese patients due to weight loss effect 1, 3
• Candesartan (angiotensin receptor blocker) - alternative first-line option 1

Second-Line Preventive Medications

• Flunarizine (calcium channel blocker) - effective for patients who fail first-line agents, and based on two randomized clinical trials, should be considered as a primary option 1, 7
• Amitriptyline or nortriptyline (tricyclic antidepressants) - particularly useful for patients with coexisting anxiety or depression 1, 6
• Venlafaxine (SNRI) - alternative for patients with mood comorbidities 5, 7
• Valproic acid - option for men, but avoid in women of childbearing potential 1, 6
• Lamotrigine - preferred when vertigo is more frequent than headaches 6, 5

Third-Line Medications (Refractory Cases)

• CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) - reserved for patients who have failed first- and second-line agents 1
• OnabotulinumtoxinA - may be considered for chronic migraine with vestibular symptoms 1
• Acetazolamide - may be reasonable for refractory patients, though its place in vestibular migraine is still being established 6, 5

Treatment Duration and Assessment

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1
• For CGRP monoclonal antibodies, assess efficacy after 3-6 months 1
• For onabotulinumtoxinA, assess efficacy after 6-9 months 1

Non-Pharmacological Interventions

• Biobehavioral therapy (relaxation techniques, stress management, biofeedback) can be as effective as pharmacological approaches and should be combined with medication 1, 4
• Vestibular rehabilitation is useful when there are complications such as loss of confidence in balance or visual dependence 6, 7
• Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medication is contraindicated 1
• Acupuncture has some supporting evidence, though not superior to sham acupuncture 1

Comorbidity Management

• Identify and treat comorbid conditions including depression, anxiety, sleep disorders, obesity, and chronic pain, as their management directly improves migraine outcomes 3, 2
• Weight loss is crucial in obese patients as obesity is a risk factor for transformation from episodic to chronic migraine 3

Patient Education

• Educate patients that vestibular migraine is a neurological disorder with a biological basis requiring multimodal treatment 1, 3
• Set realistic expectations that efficacy is rarely observed immediately and may take several weeks to months 1
• Emphasize that failure of one preventive treatment does not predict failure of other drug classes 1
• Explain that treatment adherence improves with simplified dosing schedules 1

Critical Pitfalls to Avoid

• Do not overuse vestibular suppressant medications for long-term management - these are only for acute attacks 1
• Do not allow unlimited acute medication use - strict limitation to twice weekly prevents medication overuse headache 1, 2
• Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 1, 2
• Do not abandon treatment prematurely - efficacy takes weeks to months to establish 1
• Do not fail to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 1
• Ensure adequate follow-up to assess treatment response 1