What is the best treatment approach for a patient with vestibular migraine?

Vestibular Migraine Treatment

For vestibular migraine, begin with lifestyle modifications (dietary triggers, sleep hygiene, stress management) as first-line therapy, followed by preventive medications—specifically beta blockers (propranolol, metoprolol, atenolol), topiramate, or candesartan—when symptoms occur ≥2 days per month, while reserving triptans and antiemetics for acute symptom relief during attacks. 1

Acute Attack Management

For immediate symptom relief during acute vestibular migraine attacks:

• Antiemetic medications such as diphenhydramine, meclizine, or metoclopramide can ameliorate acute vestibular symptoms 1, 2
• Triptans (sumatriptan, rizatriptan, zolmitriptan) may be used to treat concurrent headache, though evidence specifically for vestibular symptoms is very limited 1, 3
• Vestibular suppressants should only be used during acute attacks, not for long-term management, as prolonged use risks dependency and medication overuse headache 1
• Benzodiazepines may help with acute symptoms but carry significant risk of drug dependence and should be used with extreme caution 1

Critical Pitfall for Acute Treatment

Limit triptans to fewer than 10 days per month and simple analgesics to fewer than 15 days per month to prevent medication overuse headache, which can worsen the overall condition 1. The Cochrane review found very low-certainty evidence that triptans improve vertigo symptoms in vestibular migraine, meaning we cannot be confident they help the vestibular component specifically 3.

Preventive Pharmacotherapy

When attacks occur ≥2 days per month despite optimized acute treatment, initiate preventive therapy using this hierarchical approach:

First-Line Preventive Agents

• Beta blockers (propranolol, metoprolol, atenolol, or bisoprolol) are first-line agents, particularly beneficial in patients with comorbid hypertension 1
• Topiramate 50-100 mg oral daily is first-line, especially beneficial in obese patients, though common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss 1
• Candesartan (angiotensin receptor blocker) is first-line, particularly useful in hypertensive patients 1

Second-Line Preventive Agents

• Flunarizine 5-10 mg oral once daily is effective for prevention in patients who fail first-line agents, but should be avoided in patients with Parkinsonism or depression 1
• Amitriptyline 10-100 mg oral at night or nortriptyline are particularly useful for patients with coexisting anxiety or depression 1
• Valproic acid 600-1,500 mg oral once daily is an option for men, but is absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line for Refractory Cases

• CGRP monoclonal antibodies (erenumab 70 or 140 mg subcutaneous once monthly, fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly, galcanezumab, eptinezumab 100 or 300 mg intravenous quarterly) should be considered for patients who have failed first- and second-line agents 1
• OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks may be considered for chronic migraine with vestibular symptoms, as it is the only FDA-approved therapy for prophylaxis of headache in adults with chronic migraine 1

Medications to Avoid

Never prescribe oral ergot alkaloids, opioids, or barbiturates due to questionable efficacy with considerable adverse effects and dependency risk 1.

Lifestyle and Non-Pharmacological Interventions

These interventions should be implemented for all patients as foundational therapy:

• Dietary modifications: Limit salt/sodium intake (1500-2300 mg daily), avoid excessive caffeine, alcohol, and nicotine, eat well-balanced meals, maintain adequate hydration 1
• Sleep hygiene: Establish regular sleep patterns, as sleep disruption is a common trigger 1
• Stress management: Regular exercise, relaxation techniques, and biofeedback can be as effective as pharmacological approaches and should be combined with medication 1, 2
• Trigger identification: Encourage patients to maintain a headache diary to identify and avoid personal triggers 1
• Vestibular rehabilitation: Not recommended for acute attacks, but may be useful for chronic imbalance between attacks 4

Treatment Assessment and Duration

• Assess 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
• For CGRP monoclonal antibodies, assess efficacy after 3-6 months 1
• For onabotulinumtoxinA, assess efficacy after 6-9 months 1
• Use validated disability tools such as the Migraine Disability Assessment Score and HIT-6 to track treatment response 1

Diagnostic Differentiation

Before committing to treatment, ensure accurate diagnosis by ruling out:

• Ménière's disease: Distinguished by documented low-to-mid-frequency sensorineural hearing loss on audiometry and longer duration of vertigo attacks (20 minutes to 12 hours) 4
• Benign paroxysmal positional vertigo (BPPV): Triggered by specific head positions, brief duration (seconds to minutes) 1
• Vestibular neuritis: Single prolonged episode rather than recurrent attacks 1
• Central causes: Stroke, multiple sclerosis, which require neuroimaging when red flags present 1

Critical Diagnostic Consideration

35% of Ménière's disease patients also meet criteria for vestibular migraine 4. When there is uncertainty between these diagnoses, proceed through noninvasive therapeutic trials prior to any surgical or inner ear ablative interventions, which should be reserved for those with severe progressive hearing loss 4.

Comorbidity Management

Identify and manage modifiable risk factors that worsen outcomes:

• Obesity, medication overuse, excessive caffeine use 1
• Obstructive sleep apnea 1
• Psychiatric comorbidities (anxiety, depression) require concurrent treatment, as these are common in vestibular migraine and worsen outcomes 1, 5
• Chronic stress requires active management strategies 1

Patient Education Essentials

• Set realistic expectations: Efficacy is rarely observed immediately and may take several weeks to months 1
• Emphasize adherence: Treatment adherence improves with simplified dosing schedules 1
• Explain treatment failures: Failure of one preventive treatment does not predict failure of other drug classes 1
• Educate on the biological basis: Patients should understand this is a neurological disorder requiring multimodal therapy 1