What are the management options for vestibular migraine symptoms?

Vestibular Migraine: Symptoms and Management

Clinical Presentation

Vestibular migraine presents with episodic vestibular symptoms (vertigo, disequilibrium, or imbalance) lasting 5 minutes to 72 hours, occurring with or without concurrent headache, and requires ≥5 such episodes for diagnosis. 1

Key diagnostic features include:

• Vestibular symptoms: vertigo, disequilibrium, imbalance, or visual vertigo that worsen with activity and head movements 1, 2
• Duration: episodes last 5 minutes to 72 hours, most commonly minutes to hours 1, 3
• Migraine features: must be present during ≥50% of episodes, including headache, photophobia, phonophobia, or visual aura 1
• Frequency: lifetime prevalence of 3.2%, accounting for up to 14% of vertigo cases 1

Critical examination findings to assess:

• Nystagmus patterns: downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, or gaze-evoked nystagmus all suggest central pathology rather than vestibular migraine and require neuroimaging 4
• Cranial nerve examination: dysarthria, dysphagia, dysmetria, sensory/motor deficits, or Horner's syndrome indicate brainstem/cerebellar pathology 4
• Hearing loss: should be absent in vestibular migraine; its presence suggests alternative diagnoses like Meniere's disease 2

Management Algorithm

Step 1: Lifestyle Modifications (First-Line for All Patients)

Begin with dietary and lifestyle modifications as these are the foundation of vestibular migraine management. 1

Specific interventions include:

• Dietary: limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine, eat well-balanced meals, maintain adequate hydration 1
• Sleep hygiene: establish regular sleep patterns with consistent bedtime and wake times 1
• Stress management: implement stress reduction techniques, regular exercise, and biobehavioral therapy 1
• Trigger identification: identify and manage allergies and other personal triggers 1

Step 2: Acute Attack Management

For acute vestibular migraine attacks, use vestibular suppressants and antiemetics, reserving triptans for concurrent headache. 1

Acute treatment options:

• Antiemetics: diphenhydramine or meclizine to ameliorate symptoms during attacks 1
• Vestibular suppressants: centrally acting anticholinergic drugs like scopolamine can suppress acute vertigo, though with significant side effects 1
• Benzodiazepines: may help with acute symptoms but carry risk of drug dependence and should not be used long-term 1
• Triptans: effective for concurrent headache in vestibular migraine patients, though data for vertigo symptoms specifically are conflicting 1, 5

Critical pitfall: Avoid long-term use of vestibular suppressants, as they are only recommended for acute attacks 1

Step 3: Preventive Pharmacotherapy (When Symptoms Occur ≥2 Days/Month)

Initiate preventive medication when vestibular migraine symptoms occur ≥2 days per month despite optimized acute treatment and lifestyle modifications. 1

First-Line Preventive Medications:

Beta blockers (preferred in patients with comorbid hypertension, avoid in asthma):

• Propranolol, metoprolol, atenolol, or bisoprolol 1, 3

Topiramate (50-100 mg oral daily):

• Especially beneficial in obese patients 1

Candesartan (angiotensin receptor blocker):

• First-line option, particularly useful in hypertensive patients 1

Second-Line Preventive Medications:

Flunarizine (5-10 mg oral once daily):

• Based on two randomized clinical trials, should be considered the preferred preventive option when first-line agents fail 5
• Avoid in patients with Parkinsonism or depression 1

Tricyclic antidepressants:

• Amitriptyline (10-100 mg oral at night) or nortriptyline 1, 3
• Particularly useful for patients with coexisting anxiety or depression 1

Valproic acid (600-1,500 mg oral once daily):

• Option for men only; absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Venlafaxine (SNRI):

• Alternative second-line option 2, 5

Lamotrigine:

• Preferred when vertigo is more frequent than headaches 3, 2

Third-Line Preventive Medications (Refractory Cases):

CGRP monoclonal antibodies:

• Erenumab (70 or 140 mg subcutaneous once monthly) 1
• Fremanezumab (225 mg subcutaneous once monthly or 675 mg quarterly) 1
• Galcanezumab 1
• Eptinezumab (100 or 300 mg intravenous quarterly) 1

OnabotulinumtoxinA:

• 155-195 units to 31-39 sites every 12 weeks for chronic migraine with vestibular symptoms 1

Acetazolamide:

• May be reasonable for refractory patients, though its place in vestibular migraine is still being established 3, 2

Step 4: Non-Pharmacological Preventive Approaches

Vestibular rehabilitation should be incorporated, particularly when patients develop loss of confidence in balance or visual dependence 3, 6

Additional options:

• Biobehavioral therapy: relaxation techniques, stress management, and biofeedback can be as effective as pharmacological approaches and should be combined with medication 1
• Neuromodulatory devices: can be considered as adjuncts or stand-alone treatment when medication is contraindicated 1, 5
• Acupuncture: has some supporting evidence though not superior to sham acupuncture 1

Treatment Assessment and Duration

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

Specific timelines:

• Oral preventives: evaluate after 2-3 months at therapeutic dose 1
• CGRP monoclonal antibodies: assess efficacy after 3-6 months 1
• OnabotulinumtoxinA: assess efficacy after 6-9 months 1
• Treatment pause: consider pausing preventive therapy after 6-12 months of successful control to determine if it can be stopped 1

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

Critical Medications to Avoid

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

Specific concerns:

• Opioids: can lead to dependency, rebound headaches, and eventual loss of efficacy 7
• Barbiturates: risk of dependency and medication overuse headache 1
• Overuse of acute medications: risks medication overuse headache; closely monitor use 7, 1

Common Pitfalls to Avoid

• Premature treatment abandonment: do not abandon treatment prematurely, as efficacy takes weeks to months to establish 1
• Missing central pathology: 10% of cerebellar strokes can present similarly to peripheral vestibular processes; always assess for brainstem/cerebellar signs 4
• Failure to recognize comorbidities: anxiety, depression, and sleep disturbances must be identified and managed 1
• Inadequate follow-up: regular monitoring is essential to assess treatment response and screen for latent audiovestibular end-organ disease 1, 8
• Failure of one drug class: does not predict failure of other drug classes; trial alternative preventive medications 1