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

Vestibular Migraine Treatment

Begin with lifestyle modifications and dietary changes as first-line therapy, then escalate to preventive pharmacotherapy with beta blockers (propranolol, metoprolol, atenolol), topiramate, or candesartan when symptoms occur ≥2 days per month despite optimized acute treatment. 1

Initial Management: Lifestyle and Dietary Modifications

Start all patients with these non-pharmacological interventions before considering medications: 1

• Limit salt/sodium intake to 1500-2300 mg daily to reduce fluid accumulation 1
• Avoid excessive caffeine, alcohol, and nicotine as these are common triggers 1
• Maintain adequate hydration and eat well-balanced meals 1
• Establish regular sleep patterns and manage stress through relaxation techniques 1
• Implement regular exercise, which is as effective as pharmacological approaches when combined with other interventions 1
• Identify and manage allergies, which may contribute to symptoms 1
• Have patients maintain a symptom diary to identify personal triggers 1

Acute Attack Management

For acute vestibular migraine attacks, use vestibular suppressants and antiemetics for symptom relief only during the attack itself—never for long-term management: 1

• Antihistamines: diphenhydramine or meclizine for acute vertigo 1, 2
• Benzodiazepines may help acute symptoms but carry significant risk of drug dependence—use with extreme caution 1
• Centrally acting anticholinergics like scopolamine can suppress acute vertigo but have significant side effects 1
• Triptans can be used to treat concurrent headache, though evidence for vertigo improvement is very uncertain 1, 3

Critical pitfall: Avoid overuse of vestibular suppressants—they are not recommended for long-term management and can lead to medication overuse headache 1

Preventive Pharmacotherapy: First-Line Agents

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

Beta Blockers (First-Line)

• Propranolol, metoprolol, atenolol, or bisoprolol 1
• Particularly useful in patients with comorbid hypertension 1
• Assess efficacy after 2-3 months at therapeutic dose 1

Topiramate (First-Line)

• Dose: 50-100 mg oral daily 1
• Especially beneficial in obese patients 1
• Common adverse effects include cognitive inefficiency, paresthesia, fatigue, and weight loss 1

Candesartan (First-Line)

• Angiotensin receptor blocker option 1
• Particularly useful in hypertensive patients 1

Preventive Pharmacotherapy: Second-Line Agents

Consider these options when first-line agents fail or are contraindicated: 1

Flunarizine

• Dose: 5-10 mg oral once daily 1
• Calcium channel blocker effective for prevention 1
• Avoid in patients with Parkinsonism or depression 1

Tricyclic Antidepressants

• Amitriptyline 10-100 mg oral at night or nortriptyline 1
• Particularly useful for patients with coexisting anxiety or depression 1

Valproic Acid

• Dose: 600-1,500 mg oral once daily 1
• Option for men only 1
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Preventive Pharmacotherapy: Third-Line Agents for Refractory Cases

Reserve these for patients who have failed first- and second-line agents: 1

CGRP Monoclonal Antibodies

• Erenumab 70 or 140 mg subcutaneous once monthly 1
• Fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly 1
• Eptinezumab 100 or 300 mg intravenous quarterly 1
• Galcanezumab (dosing per standard migraine protocols) 1
• Assess efficacy after 3-6 months 1

OnabotulinumtoxinA

• Dose: 155-195 units to 31-39 sites every 12 weeks 1
• Only FDA-approved therapy for prophylaxis of headache in adults with chronic migraine 1
• Consider for chronic migraine with vestibular symptoms 1
• Assess efficacy after 6-9 months 1

Non-Pharmacological Adjunctive Therapies

These can be as effective as pharmacological approaches and should be combined with medication: 1

• Biobehavioral therapy including relaxation techniques, stress management, and biofeedback 1, 2
• Vestibular rehabilitation for chronic imbalance between attacks (not for acute attacks) 1
• Neuromodulatory devices as adjuncts or stand-alone treatment when medication is contraindicated 1
• Acupuncture has some supporting evidence, though not superior to sham acupuncture 1

Treatment Duration and Monitoring

Follow this timeline for assessing treatment efficacy: 1

• Assess 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
• Encourage patients to maintain a headache diary to facilitate monitoring of migraine attacks and vestibular episodes 1
• Use validated disability tools such as the Migraine Disability Assessment Score and HIT-6 to track treatment response 1

Medications to AVOID

Never prescribe these due to questionable efficacy with considerable adverse effects and dependency risk: 1

• Oral ergot alkaloids 1
• Opioids (risk of dependency, rebound headaches, and eventual loss of efficacy) 1
• Barbiturates (risk of dependency and medication overuse headache) 1

Medication Overuse Prevention

Limit acute medication use to prevent medication overuse headache: 1

• Simple analgesics: fewer than 15 days/month 1
• Triptans: fewer than 10 days/month 1

Comorbidity Management

Identify and manage these modifiable risk factors that worsen vestibular migraine: 1

• Obesity 1
• Medication overuse 1
• Caffeine use 1
• Obstructive sleep apnea 1
• Psychiatric comorbidities (anxiety, depression) 1
• Stress 1

Diagnostic Considerations

Rule out these conditions that can mimic vestibular migraine: 1

• Benign paroxysmal positional vertigo (BPPV) 1
• 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) 1
• Note that 35% of Ménière's disease patients also meet criteria for vestibular migraine 1
• Central causes: stroke, multiple sclerosis 1
• Vestibular neuritis 1

Patient Education Essentials

Set realistic expectations to improve adherence: 1

• Educate patients on the biological basis of the disorder requiring multimodal therapy 1
• Emphasize that efficacy is rarely observed immediately and may take several weeks to months 1
• Explain that failure of one preventive treatment does not predict failure of other drug classes 1
• Treatment adherence improves with simplified dosing schedules 1

Critical Pitfalls to Avoid

• Do not abandon treatment prematurely—efficacy takes weeks to months to establish 1
• Avoid inadequate follow-up to assess treatment response 1
• Do not fail to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances 1