What is the recommended management for vestibular migraine?

Management of Vestibular Migraine

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

Initial Management Approach

Lifestyle and Dietary Modifications (First-Line)

• Implement dietary restrictions including limiting salt/sodium intake, avoiding excessive caffeine, alcohol, and nicotine 1
• Ensure well-balanced meals with adequate hydration 1
• Establish regular sleep patterns and manage stress through relaxation techniques 1
• Incorporate regular exercise into the treatment plan 1
• Identify and manage allergies that may trigger symptoms 1
• Use a headache diary to identify personal triggers 2

Patient Education

• Explain that vestibular migraine has diagnostic criteria requiring ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 1
• Set realistic expectations that efficacy takes several weeks to months to establish, not immediate relief 1
• Emphasize that failure of one preventive treatment does not predict failure of other drug classes 1

Acute Attack Management

Symptomatic Treatment

• Use antiemetic medications such as diphenhydramine or meclizine (25-100 mg daily in divided doses) to ameliorate acute symptoms 1, 3
• Consider metoclopramide for significant nausea or vomiting 4
• Vestibular suppressants like scopolamine can suppress acute vertigo attacks, though with significant side effects 1
• Benzodiazepines may help with acute symptoms but carry risk of drug dependence 1

Migraine-Specific Acute Treatment

• Triptans can be used to treat concurrent headache during vestibular migraine attacks 1
• NSAIDs (ibuprofen 400-800 mg every 6 hours, naproxen sodium 275-550 mg every 2-6 hours) for mild to moderate attacks 5

Critical Pitfall

• Avoid long-term use of vestibular suppressants; they are only for acute attacks, not chronic management 1

Preventive Pharmacotherapy

Indications for Preventive Treatment

• Symptoms occurring ≥2 days per month despite optimized acute treatment 1
• Frequent attacks causing significant disability 2

First-Line Preventive Medications

Beta Blockers (Preferred for Hypertensive Patients)

• Propranolol, metoprolol, atenolol, or bisoprolol 1
• Particularly useful in patients with comorbid hypertension 1
• Avoid in patients with asthma 6

Topiramate

• Dose: 50-100 mg oral daily 1
• Especially beneficial in obese patients 1
• First-line for chronic migraine due to lower cost 2

Candesartan (Angiotensin Receptor Blocker)

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

Second-Line Preventive Medications

Flunarizine

• Dose: 5-10 mg oral once daily 1
• Based on two randomized clinical trials, should be considered the preferred preventive option when first-line agents fail 1, 7
• Avoid in patients with Parkinsonism or depression 1

Tricyclic Antidepressants

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

Valproic Acid

• Dose: 600-1,500 mg oral once daily 1
• Option for men only 1
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line 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

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

Treatment Assessment and Duration

Monitoring Timeline

• Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose 1
• For CGRP monoclonal antibodies, assess efficacy after 3-6 months 1
• For onabotulinumtoxinA, assess efficacy after 6-9 months 1

Treatment Duration

• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1

Non-Pharmacological Approaches

Behavioral Interventions

• Biobehavioral therapy including relaxation techniques, stress management, and biofeedback can be as effective as pharmacological approaches 1
• Should be combined with medication for optimal results 1
• Vestibular rehabilitation may be useful when complications like loss of confidence in balance or visual dependence develop 6

Neuromodulatory Devices

• Can be considered as adjuncts or stand-alone treatment when medication is contraindicated 1

Acupuncture

• Has some supporting evidence for prevention, though not superior to sham acupuncture 1

Critical Medications to Avoid

Absolutely Contraindicated

• Avoid oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 1, 2
• Opioids carry risk of dependency, rebound headaches, and eventual loss of efficacy 2

Medication Overuse Prevention

• Limit acute medications to no more than 2-3 days per week to prevent medication overuse headache 2
• Monitor for transformation to chronic migraine 5

Comorbidity Management

Essential Screening

• Assess for and manage anxiety, depression, and sleep disturbances 2
• Consider medications like amitriptyline that address both vestibular migraine and comorbid conditions 5
• Identify and treat obesity, cardiovascular risk factors 5

Diagnostic Considerations Before Treatment

Rule Out Alternative Diagnoses

• Exclude central causes (stroke, multiple sclerosis) by appropriate investigations 1
• Distinguish from benign paroxysmal positional vertigo (BPPV), Ménière's disease, and vestibular neuritis 1
• Monitor for development of latent audiovestibular end-organ disease 8

Common Pitfalls to Avoid

• Do not abandon treatment prematurely; efficacy takes weeks to months to establish 1
• Avoid overuse of acute medications which risks medication overuse headache 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
• Simplified dosing schedules improve treatment adherence 1