First-Line Treatment for Vestibular Migraine
For vestibular migraine prophylaxis, flunarizine should be considered the first-line treatment based on randomized clinical trial evidence, with propranolol, topiramate, venlafaxine, and amitriptyline as alternative first-line options when flunarizine is unavailable or contraindicated. 1
Prophylactic Treatment Strategy
The mainstay of vestibular migraine management is prophylactic medication rather than acute treatment, as specific antimigraine drugs are unlikely to be very effective for rescue during attacks. 2
First-Line Prophylactic Options
Flunarizine is the preferred first-line agent based on two randomized clinical trials demonstrating efficacy specifically for vestibular migraine, making it the only medication with Level 1 evidence for this condition. 1
Propranolol (80-240 mg/day) is an effective alternative first-line option, particularly useful in patients with comorbid hypertension but contraindicated in those with asthma. 3, 4, 2
Topiramate (typically 50 mg twice daily, up to 100 mg/day) has demonstrated efficacy in reducing both vestibular symptoms and headache in vestibular migraine patients (p<0.001), and is particularly beneficial when patients are obese. 3, 4, 2
Amitriptyline (30-150 mg/day) is effective for vestibular migraine prophylaxis (p<0.001 for symptom improvement) and is especially useful when patients have comorbid anxiety or mixed migraine and tension-type headache. 3, 4, 2
Venlafaxine is recommended as a first-line option, particularly when patients have comorbid anxiety or depression. 5, 1
Second-Line Prophylactic Options
Valproic acid (800-1500 mg/day) can be used but is strictly contraindicated in women of childbearing potential due to teratogenic effects. 3, 2, 1
Lamotrigine may be reasonable for refractory patients and is preferred when vertigo attacks are more frequent than headaches. 5, 2
Acetazolamide may be considered for refractory cases, though its place in vestibular migraine treatment is still being established. 5, 2
Metoprolol is an alternative beta-blocker option for patients who cannot tolerate propranolol. 3, 2
Acute Attack Treatment
Triptans (such as sumatriptan, rizatriptan, or zolmitriptan) may be effective for acute vestibular migraine attacks, though available data are conflicting and they are less effective than for typical migraine. 6, 5, 1
Generic antivertiginous and antiemetic drugs are used for long-lasting individual attacks, as specific antimigraine drugs are unlikely to be very effective for rescue. 2
Neurostimulating devices can be considered as an alternative acute treatment option. 1
Non-Pharmacological Treatment
Vestibular rehabilitation is a sound prophylactic treatment option and may be helpful for patients with loss of confidence in balance or visual dependence. 5, 2, 1
Lifestyle modifications including dietary changes, sleep hygiene, and avoidance of triggers are recommended as adjunctive measures. 2
Implementation Considerations
Allow an adequate trial period of 2-3 months before determining efficacy of prophylactic medications, as this is the standard timeframe for oral preventive agents. 3
Start with low doses and titrate slowly until clinical benefits are achieved or side effects limit further increases. 3
Prophylactic treatment is indicated when patients experience two or more attacks per month with disability lasting 3 or more days, or when acute treatments fail or are contraindicated. 3
80.9% of vestibular migraine patients show improvement with prophylaxis (p<0.001), with longer duration of vestibular symptoms associated with greater benefit from prophylactic treatment. 4
Critical Pitfalls to Avoid
Do not rely solely on acute treatment for vestibular migraine, as prophylactic medication is the mainstay of management and specific antimigraine drugs are unlikely to be very effective for rescue. 2
Avoid inadequate trial duration (less than 2-3 months) before declaring a prophylactic medication ineffective. 3
Do not prescribe valproate to women of childbearing potential due to severe teratogenic effects. 3, 2
Avoid starting with excessively high doses, which leads to poor tolerability and discontinuation. 3