What are the treatment options for vestibular migraines?

Treatment for Vestibular Migraine

Begin with lifestyle modifications and dietary changes as first-line therapy, then escalate to preventive medications (beta blockers, topiramate, or candesartan) when symptoms occur ≥2 days per month, while reserving acute symptomatic treatment with antiemetics and triptans for active attacks. 1

Initial Management: Lifestyle and Dietary Modifications

All patients should start with non-pharmacological interventions before considering medications. 1 These include:

• Limiting salt/sodium intake (particularly important, as this overlaps with Ménière's disease management principles) 1
• Avoiding excessive caffeine, alcohol, and nicotine 1
• Eating well-balanced meals and maintaining adequate hydration 1
• Managing stress through relaxation techniques and biofeedback 1
• Regular exercise and establishing regular sleep patterns 1
• Identifying and managing allergies 1

These lifestyle modifications are recommended by the American Academy of Otolaryngology-Head and Neck Surgery as first-line interventions and should not be skipped. 1

Acute Attack Management

For active vestibular migraine attacks, use antiemetic medications to control symptoms, not long-term vestibular suppressants. 1

Symptomatic Relief During Attacks:

• Diphenhydramine or meclizine can ameliorate acute vestibular symptoms 1, 2
• Benzodiazepines may help with acute symptoms but carry risk of drug dependence 1
• Metoclopramide can be used as an antiemetic 2

Migraine-Specific Acute Treatment:

• Triptans can be used to treat concurrent headache during vestibular migraine attacks 1, 3, 4
• However, triptans are unlikely to be very effective for the vestibular symptoms themselves 5

Critical Pitfall:

Avoid long-term use of vestibular suppressants (like meclizine or scopolamine) - these are only for acute attacks, not chronic management. 1 The American Academy of Otolaryngology-Head and Neck Surgery specifically warns against overuse of these medications. 1

Preventive Pharmacological Treatment

Preventive medications should be initiated when symptoms occur ≥2 days per month despite optimized acute treatment. 1

First-Line Preventive Agents:

Beta blockers are the preferred first-line option, especially in patients with comorbid hypertension: 1

• Propranolol 1, 5
• Metoprolol 1, 5
• Atenolol 1
• Bisoprolol 1
• Avoid in patients with asthma 5

Topiramate is first-line, particularly beneficial in obese patients 1, 5

Candesartan (angiotensin receptor blocker) is a first-line option 1

Second-Line Preventive Medications:

Flunarizine (calcium channel blocker) - Based on two randomized clinical trials, this should be considered as a primary treatment option for patients who fail first-line agents 1, 3

Tricyclic antidepressants (amitriptyline or nortriptyline) - particularly useful for patients with coexisting anxiety or depression 1, 5, 2

Valproic acid - an option for men, but should be avoided in women of childbearing potential 1, 5

Lamotrigine - preferred if vertigo is more frequent than headaches 5, 4

Venlafaxine (SSRI) - can be considered, especially with comorbid anxiety 3, 4

Third-Line Options for Refractory Cases:

CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab, eptinezumab) should be considered for patients who have failed first- and second-line agents 1

OnabotulinumtoxinA may be considered for chronic migraine with vestibular symptoms 1

Non-Pharmacological Preventive Approaches

Biobehavioral therapy can be as effective as pharmacological approaches and should be combined with medication: 1

• Relaxation techniques 1
• Stress management 1
• Biofeedback 1, 2

Vestibular rehabilitation should be considered for all patients with vestibular migraine, particularly those with persistent dizziness, chronic imbalance, or incomplete recovery 6, 2, 3

Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medication is contraindicated 1

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

Critical Pitfalls to Avoid

Do not use oral ergot alkaloids, opioids, or barbiturates - these have questionable efficacy with considerable adverse effects and dependency risk 1

Avoid overuse of acute medications - this risks medication overuse headache 1

Do not abandon treatment prematurely - efficacy takes weeks to months to establish, and failure of one preventive treatment does not predict failure of other drug classes 1

Set realistic expectations - efficacy is rarely observed immediately and may take several weeks to months 1

Ensure adequate follow-up to assess treatment response 1