What is the outpatient management for a patient with migraine-associated vertigo (benign paroxysmal positional vertigo, BPPV)?

From the Guidelines

Outpatient management of migraine with vertigo should prioritize a canalith repositioning procedure as initial therapy for patients with posterior canal BPPV, as recommended by the most recent and highest quality study 1. The management of migraine with vertigo, also known as vestibular migraine, involves both acute treatment and preventive strategies. For acute episodes, triptans like sumatriptan (50-100mg orally) or rizatriptan (10mg) can address both headache and vertigo symptoms. Anti-emetics such as promethazine (12.5-25mg) or ondansetron (4-8mg) help manage associated nausea. Vestibular suppressants like meclizine (12.5-25mg every 4-6 hours) or diazepam (2-5mg) can temporarily relieve vertigo during attacks. Some key points to consider in the management of migraine with vertigo include:

• Diagnosis of posterior semicircular canal BPPV using the Dix-Hallpike maneuver, as described in the clinical practice guideline 1
• Differentiation of BPPV from other causes of imbalance, dizziness, and vertigo, as recommended in the guideline 1
• Assessment of patients with BPPV for factors that modify management, including impaired mobility or balance, central nervous system disorders, a lack of home support, and/or increased risk for falling, as stated in the guideline 1
• The use of canalith repositioning procedures as initial therapy for patients with posterior canal BPPV, as strongly recommended by the guideline 1
• The option to offer vestibular rehabilitation, either self-administered or with a clinician, in the treatment of BPPV, as stated in the guideline 1
• The recommendation against routinely treating BPPV with vestibular suppressant medications such as antihistamines and/or benzodiazepines, as stated in the guideline 1 For prevention, first-line options include propranolol (40-160mg daily), topiramate (25-100mg twice daily), or amitriptyline (10-50mg nightly). Lifestyle modifications are essential, including trigger avoidance (certain foods, irregular sleep, stress), maintaining regular sleep patterns, and vestibular rehabilitation exercises to improve balance. Patients should keep a symptom diary to identify triggers and evaluate treatment effectiveness. A stepwise approach is recommended, starting with lifestyle changes, then adding preventive medication if attacks occur more than 4 times monthly or significantly impact quality of life. Vestibular migraine often responds to the same treatments as typical migraine because both involve similar neurochemical pathways affecting both pain processing and vestibular function in the brain.

From the Research

Migraine with Vertigo Outpatient Management

• The management of migraine with vertigo, also known as vestibular migraine, can be challenging due to its complex pathophysiology and variable clinical presentation 2.
• Outpatient management of vestibular migraine typically involves a combination of pharmacological and non-pharmacological interventions, with the goal of reducing the frequency and severity of vertigo attacks and improving quality of life.

Pharmacological Interventions

• Topiramate has been shown to be effective in reducing the frequency and severity of vertigo and headache attacks in patients with migrainous vertigo, with a daily dose of 50 mg being a suitable starting point 3, 4.
• Flunarizine hydrochloride has also been found to be effective in reducing vertigo intensity, duration, and frequency, although it may be less effective than topiramate in some patients 4.
• Other pharmacological agents, such as metoprolol, amitriptyline, valproic acid, and diphenhydramine, may also be used in the management of vestibular migraine, although the evidence for their effectiveness is limited 5.

Non-Pharmacological Interventions

• Non-pharmacological measures, such as regular exercise, relaxation techniques, stress management, and biofeedback, may be effective in reducing the frequency and severity of vertigo attacks and improving quality of life 5.
• Explanation and reassurance are also important components of outpatient management, as many patients with vestibular migraine may experience significant anxiety and distress related to their symptoms.

Treatment Outcomes

• The effectiveness of outpatient management for vestibular migraine can vary depending on the individual patient and the specific treatment approach used, with some studies reporting significant improvements in symptoms and quality of life 3, 6, 4.
• However, the overall evidence base for vestibular migraine treatment is of low quality, and further research is needed to establish evidence-based guidelines for management 2.