What is the management of vestibular migraine?

Management of Vestibular Migraine

Vestibular migraine management begins with lifestyle modifications and dietary changes as first-line interventions, followed by preventive pharmacotherapy with beta-blockers (propranolol, metoprolol, atenolol), topiramate, or candesartan when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Acute Attack Management

For acute vestibular migraine attacks, use vestibular suppressants and antiemetics for symptomatic relief, but avoid long-term use of these agents. 1

• Antiemetic medications such as diphenhydramine, meclizine, and metoclopramide can ameliorate symptoms during acute attacks 1, 2
• Centrally acting anticholinergic drugs like scopolamine can suppress acute vertigo attacks, though they carry significant side effects 1
• Benzodiazepines may help with acute symptoms but carry a risk of drug dependence 1
• Triptans can be used to treat concurrent headache in patients with vestibular migraine, though their effectiveness for the vestibular symptoms themselves is limited 1, 3

Critical pitfall: Vestibular suppressants are not recommended for long-term management—they should only be used during acute attacks. 1

Preventive Pharmacotherapy

First-Line Preventive Medications

Beta-blockers are the preferred first-line preventive agents, particularly in patients with comorbid hypertension. 1, 4

• Propranolol, metoprolol, atenolol, or bisoprolol are all effective options 1, 3
• Contraindicated in patients with asthma 3

Topiramate 50-100 mg oral daily is a first-line option, especially beneficial in obese patients. 5, 1, 4

Candesartan is a first-line angiotensin receptor blocker option. 1, 4

Second-Line Preventive Medications

When first-line agents fail, consider tricyclic antidepressants or calcium channel blockers. 1

• Amitriptyline 10-100 mg oral at night or nortriptyline are particularly useful for patients with coexisting anxiety or depression 5, 1, 3
• Flunarizine 5-10 mg oral once daily is effective for prevention in patients who fail first-line agents, though it should be avoided in patients with Parkinsonism or depression 5, 1
• Valproic acid 600-1,500 mg oral once daily is an option for men, but is absolutely contraindicated in women of childbearing potential due to teratogenicity 5, 3

Third-Line Preventive Medications

For refractory cases that have failed first- and second-line agents, consider CGRP monoclonal antibodies or onabotulinumtoxinA. 1

• CGRP monoclonal antibodies (erenumab 70 or 140 mg subcutaneous once monthly, fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly, eptinezumab 100 or 300 mg intravenous quarterly) should be considered as third-line medications 5, 1
• OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks may be considered for chronic migraine with vestibular symptoms 5, 1

Non-Pharmacological Interventions

Lifestyle modifications are essential first-line interventions and should be implemented in all patients. 1

• Limit salt/sodium intake 1
• Avoid excessive caffeine, alcohol, and nicotine 1
• Eat well-balanced meals and maintain adequate hydration 1
• Manage stress through relaxation techniques and biofeedback 1, 2
• Regular exercise 1, 2
• Establish regular sleep patterns 1
• Identify and manage allergies 1

Biobehavioral therapy, including relaxation techniques, stress management, and biofeedback, can be as effective as pharmacological approaches and should be combined with medication. 1, 2

Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence. 3

Treatment Duration and Assessment

Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose. 1, 4

• 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

Use headache calendars to track attack frequency, severity, and medication use. 4

Critical Pitfalls to Avoid

Avoid overuse of acute medications, as this risks medication overuse headache. 1, 4

• Limit triptan use to <10 days per month 4
• Limit NSAID use to <15 days per month 4

Do not abandon treatment prematurely—efficacy takes weeks to months to establish. 1

Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy with considerable adverse effects and dependency risk. 5, 1

Ensure adequate follow-up to assess treatment response—inadequate follow-up is a common pitfall. 1

Failure of one preventive treatment does not predict failure of other drug classes—try alternative medications if initial therapy fails. 1