What is the recommended evaluation and treatment approach for a pediatric patient presenting with symptoms of vestibular migraine?

Pediatric Vestibular Migraine: Evaluation and Treatment

Diagnostic Approach

Begin with the International Classification of Headache Disorders criteria: ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, with migraine history and migrainous features during ≥50% of episodes. 1

Essential History Components

• Vertigo characteristics: Duration (5 minutes to 72 hours typical), triggers including light sensitivity and motion intolerance, and presence of visual auras before, during, or after attacks 2
• Migraine features: Headache, photophobia, phonophobia occurring with ≥50% of vestibular episodes 1, 3
• Auditory symptoms: Hearing loss is typically mild, absent, or stable over time (unlike Ménière's disease which shows documented low-to-mid-frequency sensorineural hearing loss) 2, 1
• Family history: Positive in 65% of pediatric cases 4
• Exclude red flags: Loss of consciousness never occurs in vestibular migraine and demands alternative diagnosis; dysarthria, dysphagia, dysmetria, or focal neurologic deficits suggest central pathology 5, 6

Physical Examination Priorities

Perform cranial nerve examination and nystagmus evaluation to distinguish central from peripheral vestibular pathology. 6

• Central pathology indicators requiring neuroimaging: Downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, or baseline nystagmus without provocative maneuvers 6
• Dix-Hallpike maneuver: Classic BPPV pattern (upbeating-torsional with latency and fatigue) suggests BPPV rather than vestibular migraine 6
• Vestibular testing findings: Approximately 20% show pathological horizontal vestibulo-ocular reflex function, 50% have abnormal postural sway, and 24% demonstrate mild central ocular motor signs (most commonly horizontal saccadic pursuit) 4

When Additional Testing Is NOT Needed

Routine vestibular function testing and neuroimaging should not be obtained when clinical diagnosis is clear based on Barany Society criteria. 6

When Additional Testing IS Required

• Abnormal cranial nerves, visual disturbances beyond typical migraine aura, or severe headache suggesting intracranial pathology 6
• Atypical nystagmus patterns suggesting central pathology 6
• Unclear clinical presentation or failure to respond to appropriate treatment 6
• Multiple concurrent vestibular disorders 6

Treatment Algorithm

First-Line: Lifestyle Modifications

Initiate dietary and lifestyle modifications before pharmacological intervention. 1

• Dietary: Limit salt/sodium, avoid excessive caffeine, alcohol, and nicotine; maintain well-balanced meals and adequate hydration 1
• Sleep hygiene: Establish regular sleep patterns (adequate sleep facilitates recovery) 2, 1
• Physical activity: Regular exercise is as effective as pharmacological approaches when combined with other interventions 1
• Stress management: Implement stress reduction techniques and biobehavioral therapy 1
• Trigger avoidance: Identify and avoid specific triggers including light sensitivity and motion intolerance 2

Acute Attack Management

• Vestibular suppressants: Use for acute attacks only, not long-term (centrally acting anticholinergics like scopolamine can suppress acute vertigo but have significant side effects) 1
• Antiemetics: Diphenhydramine and meclizine help ameliorate symptoms during acute attacks 1
• Triptans: Treat concurrent headache, but limit to fewer than 10 days/month to prevent medication overuse headache 1
• Simple analgesics: Limit to fewer than 15 days/month 1

Preventive Pharmacotherapy Indications

Initiate preventive medications when symptoms occur ≥2 days per month despite optimized acute treatment and lifestyle modifications. 1

First-Line Preventive Medications

• Beta blockers: Propranolol, metoprolol, atenolol, or bisoprolol (particularly useful with comorbid hypertension) 1
• Topiramate: 50-100 mg oral daily (especially beneficial in obese patients; common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss) 1
• Candesartan: Angiotensin receptor blocker (particularly useful in hypertensive patients) 1

Second-Line Options

• Flunarizine: 5-10 mg oral once daily (avoid in patients with Parkinsonism or depression) 1
• Tricyclic antidepressants: Amitriptyline 10-100 mg at night or nortriptyline (particularly useful with coexisting anxiety or depression) 1
• Valproic acid: 600-1,500 mg oral once daily for males only (absolutely contraindicated in females of childbearing potential due to teratogenicity) 1

Third-Line 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 intravenous quarterly 1
• OnabotulinumtoxinA: 155-195 units to 31-39 sites every 12 weeks for chronic migraine with vestibular symptoms 1

Treatment Assessment Timeline

Assess efficacy of oral preventive medications after 2-3 months at therapeutic dose. 1

• For CGRP monoclonal antibodies: Assess after 3-6 months 1
• For onabotulinumtoxinA: Assess after 6-9 months 1
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1

Non-Pharmacological Adjuncts

• Vestibular rehabilitation: May be useful for chronic imbalance between attacks 1, 7
• Biobehavioral therapy: Relaxation techniques, stress management, and biofeedback can be as effective as pharmacological approaches 1
• Cognitive behavioral therapy: Important therapeutic measure, particularly with psychological comorbidities 3

Critical Pitfalls to Avoid

• Missing central pathology: 10% of cerebellar strokes present similarly to peripheral vestibular processes; always assess for brainstem/cerebellar signs 6
• Medication overuse: Avoid opioids, barbiturates, and oral ergot alkaloids due to dependency risk and questionable efficacy 1
• Premature treatment abandonment: Efficacy takes weeks to months to establish; failure of one preventive class does not predict failure of others 1
• Over-testing clear diagnoses: When Barany criteria are met, routine testing delays treatment 6
• Inadequate comorbidity management: Identify and manage obesity, medication overuse, caffeine use, obstructive sleep apnea, anxiety, depression, and stress 1

Patient Education Essentials

Educate on the biological basis requiring multimodal therapy, with realistic expectations that efficacy takes several weeks to months. 1

• Treatment adherence improves with simplified dosing schedules 1
• Encourage headache diary maintenance to track migraine attacks and vestibular episodes 1
• Use validated disability tools (Migraine Disability Assessment Score, HIT-6) to track treatment response 1