What is the best treatment for vestibular migraines?

Best Treatment for Vestibular Migraine

Start with lifestyle modifications and dietary changes as first-line therapy, then initiate prophylactic medication with beta-blockers (propranolol, metoprolol, atenolol) or topiramate when symptoms occur ≥2 days per month, with flunarizine as the preferred second-line agent based on the strongest randomized trial evidence. 1, 2

Initial Management Approach

Begin with non-pharmacological interventions before escalating to medications:

• Implement dietary modifications including limiting salt/sodium intake, avoiding excessive caffeine, alcohol, and nicotine 1
• Establish regular sleep patterns and maintain adequate hydration 1
• Incorporate stress management techniques, regular exercise, and biobehavioral therapy (relaxation training, progressive muscle relaxation, biofeedback) 3, 1
• These lifestyle measures can be as effective as pharmacological approaches and should be combined with medication when needed 1

Acute Attack Treatment

For symptomatic relief during active attacks:

• Use antiemetic medications such as diphenhydramine or meclizine to ameliorate acute vestibular symptoms 1, 4
• Triptans can be used to treat concurrent headache, though their efficacy specifically for vestibular symptoms is less established 1, 5
• Avoid long-term use of vestibular suppressants (benzodiazepines, anticholinergics) as they interfere with central vestibular compensation, cause drowsiness, cognitive deficits, and increase fall risk, especially in elderly patients 6

Prophylactic Medication Strategy

First-Line Preventive Medications (Choose Based on Comorbidities):

Beta-blockers are the primary first-line option:

• Propranolol, metoprolol, atenolol, or bisoprolol are recommended, particularly for patients with comorbid hypertension 1, 7
• Avoid in patients with asthma, bradycardia, or hypotension 7

Topiramate 50-100 mg daily:

• Especially beneficial in obese patients 1, 7
• Assess efficacy after 2-3 months at therapeutic dose 1

Candesartan (angiotensin receptor blocker):

• Particularly useful in hypertensive patients 1

Second-Line Preventive Medications:

Flunarizine 5-10 mg once daily should be considered the preferred second-line option when first-line agents fail, based on two randomized clinical trials showing superior evidence compared to other options 1, 2

• Avoid in patients with Parkinsonism or depression 1

Tricyclic antidepressants:

• Amitriptyline 10-100 mg at night or nortriptyline for patients with coexisting anxiety or depression 1, 7

Valproic acid 600-1,500 mg daily:

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

Lamotrigine:

• Preferred when vertigo is more frequent than headaches 7

Third-Line Options for Refractory Cases:

CGRP monoclonal antibodies:

• Erenumab 70-140 mg subcutaneous monthly, fremanezumab 225 mg monthly or 675 mg quarterly, or eptinezumab 100-300 mg IV quarterly 1
• Assess efficacy after 3-6 months 1

OnabotulinumtoxinA 155-195 units every 12 weeks:

• For chronic migraine with vestibular symptoms 1

Treatment Duration and Monitoring

Follow this timeline for optimal management:

• Reassess patients within 1 month after initiating treatment to document response and adjust therapy 6
• Evaluate 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
• Set realistic expectations that efficacy takes several weeks to months to establish 1

Critical Medications to Avoid

Never use these agents due to poor efficacy and significant harm:

• Oral ergot alkaloids, opioids, and barbiturates have questionable efficacy with considerable adverse effects and dependency risk 1
• Long-term vestibular suppressants should be withdrawn as soon as possible 6

Common Pitfalls to Avoid

• Do not abandon treatment prematurely - efficacy takes weeks to months to establish 1
• Avoid overuse of acute medications - this risks medication overuse headache 1
• Do not assume failure of one preventive predicts failure of others - different drug classes may work when others fail 1
• Rule out other causes of vertigo including Ménière's disease (which has hearing loss), BPPV, vestibular neuritis, and central causes like stroke or multiple sclerosis before committing to vestibular migraine treatment 1