What is the recommended treatment for a patient with vestibular migraine?

Treatment of Vestibular Migraine

The recommended treatment for vestibular migraine is prophylactic medication with beta-blockers (propranolol 80-240 mg/day or metoprolol), topiramate (100 mg/day), or calcium channel blockers (flunarizine 5-10 mg/day), combined with lifestyle modifications, as rescue medications (including triptans) have very limited evidence for acute vestibular attacks. 1, 2

Prophylactic (Preventive) Therapy: The Mainstay of Treatment

Prophylactic medication is the cornerstone of vestibular migraine management, as acute rescue treatments are unlikely to be very effective for vertigo episodes. 1

First-Line Prophylactic Agents

• Beta-blockers are preferred in patients with comorbid hypertension but should be avoided in those with asthma. 1

  • Propranolol 80-240 mg/day has strong evidence for migraine prophylaxis 3
  • Metoprolol is an effective alternative 1

• Topiramate 100 mg/day (typically 50 mg twice daily) is particularly beneficial when patients are obese due to associated weight loss. 3, 1

• Calcium channel blockers include:

  • Flunarizine 5-10 mg once daily (taken at night) is an effective second-line agent with efficacy comparable to propranolol and topiramate 3, 1
  • Verapamil is an alternative option 1

Second-Line Prophylactic Agents

• Tricyclic antidepressants (amitriptyline 30-150 mg/day or nortriptyline) are recommended when patients have comorbid anxiety or depression. 3, 1

• Anticonvulsants:

  • Valproic acid 800-1500 mg/day is effective but strictly contraindicated in women of childbearing potential due to teratogenic effects 3, 1
  • Lamotrigine is preferred when vertigo attacks are more frequent than headaches 1

• Benzodiazepines (clonazepam) may be considered for patients with significant anxiety. 1

Implementation Strategy for Prophylaxis

• Start with a low dose and titrate slowly to minimize side effects 3
• Allow an adequate trial period of 2-3 months before assessing efficacy 3
• Use headache/vertigo diaries to track attack frequency, severity, duration, and medication response 3
• Consider tapering or discontinuing treatment after 6-12 months of successful therapy 3

Acute (Rescue) Treatment: Limited Evidence

The evidence for acute treatment of vestibular migraine attacks is extremely sparse and of very low certainty. 4, 5

Triptans for Acute Attacks

• Triptans (rizatriptan 10 mg, zolmitriptan 2.5 mg) may result in little or no difference in vertigo improvement at up to 2 hours, with very low-certainty evidence 5
• Triptans are unlikely to be very effective for rescue treatment of vestibular migraine, unlike their efficacy in headache migraine 1

Symptomatic Treatment

• Vestibular suppressants (antihistamines like meclizine, benzodiazepines) and antiemetic agents may be used for symptomatic relief during long-lasting individual attacks 1, 2
• These should only be used short-term, as they can interfere with central vestibular compensation 6

Non-Pharmacological Interventions

• Lifestyle modifications are essential and include:

  • Dietary modifications and trigger avoidance 1, 2
  • Sleep hygiene optimization 1, 2
  • Stress management 2

• Lifestyle modifications alone showed no worsening of dizziness in any participant at 372 days, with 50% showing improvement by at least one severity category 7

• Vestibular rehabilitation may be useful when complications develop, such as loss of confidence in balance or visual dependence 1, 2

• Cognitive behavioral therapy, biofeedback, and relaxation training can be offered as adjuncts 3

Critical Pitfalls to Avoid

• Do not rely on triptans as primary treatment for vestibular migraine attacks, as evidence shows minimal benefit for vertigo symptoms 5
• Avoid prolonged use of vestibular suppressants (antihistamines, benzodiazepines), as they interfere with central compensation 6
• Screen for depression and Parkinson's disease before initiating flunarizine, as it may exacerbate these conditions 3
• Never prescribe valproate to women of childbearing potential due to severe teratogenic effects 3, 1
• Ensure adequate trial duration (2-3 months) before declaring prophylactic treatment ineffective 3, 1

Treatment Selection Algorithm

Choose prophylactic medication based on comorbidities:

• Hypertension without asthma → Beta-blockers (propranolol or metoprolol) 1
• Obesity → Topiramate 3, 1
• Anxiety or depression → Amitriptyline or SSRIs with benzodiazepines 1
• Vertigo more frequent than headaches → Lamotrigine 1
• Failed first-line agents → Flunarizine 5-10 mg at night 3, 1