What is the recommended treatment for vestibular migraine?

Treatment of Vestibular Migraine

For vestibular migraine, prophylactic medication is the mainstay of treatment, with flunarizine as the first-line agent based on randomized trial evidence, followed by beta-blockers (propranolol), topiramate, or tricyclic antidepressants as second-line options. 1

Acute Attack Management

For individual vestibular migraine attacks, treatment options are limited and generally less effective than prophylaxis:

• Triptans can be tried first for acute attacks, though evidence is conflicting and they are unlikely to be highly effective for rescue therapy during vestibular symptoms 2, 1
• Antiemetic medications (dimenhydrinate, prochlorperazine) should be used to control nausea and vomiting during attacks 3
• Benzodiazepines (diazepam, clonazepam) can reduce the subjective sensation of spinning in acute episodes, but should only be used short-term as they interfere with central vestibular compensation 4, 3
• Generic antivertiginous drugs may provide symptomatic relief for longer-lasting individual attacks 2

Critical caveat: Vestibular suppressants should NOT be used routinely or long-term, only for short-term management of severe acute symptoms, as they can interfere with central compensation and prolong recovery 4, 5

Prophylactic Treatment (Primary Management Strategy)

First-Line Agent

• Flunarizine should be considered the first treatment option based on two randomized clinical trials demonstrating efficacy specifically for vestibular migraine 1
• Flunarizine is a calcium channel blocker that has shown superior evidence compared to other prophylactic agents 1

Second-Line Prophylactic Agents

When flunarizine is not available, not tolerated, or ineffective, choose based on comorbidities:

• Beta-blockers (propranolol or metoprolol): Preferred in patients with hypertension but contraindicated in asthma 2, 3

  • Propranolol demonstrated 80.9% improvement in vestibular symptoms in retrospective studies 6

• Topiramate: Particularly useful when patients are obese, as it can cause weight loss 2, 3

  • Showed significant improvement in vestibular symptoms (p<0.001) 6

• Tricyclic antidepressants (amitriptyline or nortriptyline): Preferred when patients have comorbid anxiety or depression 2

  • Amitriptyline demonstrated significant improvement in both vestibular symptoms and headache (p<0.001 and p<0.015 respectively) 6

• Valproic acid: Alternative anticonvulsant option 2, 3

• Lamotrigine: Specifically preferred when vertigo attacks are more frequent than headaches 2, 3

• Venlafaxine (SSRI): Can be considered as second-line option 1

Evidence Supporting Prophylaxis

• 80.9% of vestibular migraine patients showed improvement with prophylactic therapy (p<0.001) in a study of 47 patients 6
• All four major prophylactic drugs (amitriptyline, flunarizine, propranolol, topiramate) improved both vestibular symptoms and headache in statistically significant manner 6
• No statistically significant difference exists between different prophylactic drugs, so selection should be guided by side effect profile and patient comorbidities 6
• Longer duration of vestibular symptoms appears to increase benefit from prophylactic treatment 6
• Drug combination therapy showed no additional benefit over monotherapy 6

Non-Pharmacological Management

Lifestyle Modifications (Essential Component)

• Maintain regular sleep schedules and meal times to reduce attack frequency 7
• Identify and avoid specific triggers when self-evident 7
• Ensure adequate hydration 7, 5
• Implement stress management techniques 7
• Dietary modifications as recommended for migraine 2, 3

Vestibular Rehabilitation

• Vestibular rehabilitation should be considered for all vestibular migraine patients, particularly when there is loss of confidence in balance, visual dependence, or residual symptoms despite medication 2, 3
• VR is especially useful as a prophylactic treatment option and for complications of the condition 2, 1
• Movement/habituation-based vestibular rehabilitation is necessary for increased balance performance, not repositioning procedures alone 5

Critical Pitfalls to Avoid

• Do not use vestibular suppressants as long-term therapy - they interfere with central compensation and can prolong symptoms 4, 5
• Avoid medication overuse - do not use acute medications more than 10 days per month to prevent medication overuse headache 7
• Do not give up after one prophylactic drug fails - try alternative agents as individual response varies 6
• Benzodiazepines are a significant independent risk factor for falls and should be used with extreme caution, especially in elderly patients 5
• Reassess patients within 1 month after initiating treatment to document response and ensure accurate diagnosis 4, 5

Distinguishing Vestibular Migraine from Other Causes

Vestibular migraine requires specific diagnostic criteria to distinguish from other vestibular disorders:

• ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 4
• Current or history of migraine according to International Headache Society criteria 4
• ≥1 migraine symptom during at least 50% of dizzy episodes (migrainous headache, photophobia, phonophobia, visual or other aura) 4
• Other causes ruled out by appropriate investigations 4

If symptoms fail to respond to initial prophylactic therapy, reassess to rule out central causes such as brainstem/cerebellar stroke, multiple sclerosis, or intracranial tumors 4