What are the recommended therapies for a patient with vestibular migraines, considering lifestyle modifications, preventive therapies, and medication options?

Vestibular Migraine Therapy

Begin with lifestyle modifications as first-line therapy for all patients with vestibular migraine, followed by preventive medications (beta blockers, topiramate, or candesartan) when symptoms occur ≥2 days per month despite optimized acute treatment, and reserve triptans or antiemetics for acute attacks. 1

Lifestyle and Dietary Modifications (First-Line for All Patients)

Lifestyle modifications should be implemented immediately as they are effective and carry no risk of adverse effects. 1

• Limit salt/sodium intake to reduce vestibular symptoms 1
• Avoid excessive caffeine, alcohol, and nicotine as these are common migraine triggers 1
• Eat well-balanced meals at regular intervals to prevent hypoglycemia-triggered attacks 1
• Maintain adequate hydration throughout the day 1
• Establish regular sleep patterns with consistent sleep and wake times 1
• Implement stress management techniques including relaxation training and biofeedback 1
• Engage in regular exercise, which is as effective as pharmacological approaches when combined with other interventions 1
• Identify and manage allergies that may trigger vestibular symptoms 1

Recent evidence demonstrates that lifestyle modifications alone can produce significant improvement, with 50% of patients showing reduction in dizziness severity at one year, and notably, no patients worsened with this approach alone. 2

Acute Attack Management

For acute vestibular migraine episodes, use targeted symptomatic relief while avoiding long-term vestibular suppressants. 1

Antiemetics and Vestibular Suppressants

• Diphenhydramine or meclizine can ameliorate acute vestibular symptoms 1
• Centrally acting anticholinergics (scopolamine) may suppress acute vertigo but have significant side effects 1
• Benzodiazepines may help acute symptoms but carry risk of drug dependence 1
• Critical pitfall: Vestibular suppressants are recommended for acute attacks only, not for long-term management 1

Triptans for Concurrent Headache

• Sumatriptan 50-100 mg orally can treat concurrent headache during vestibular migraine attacks 1, 3
• Limit triptan use to fewer than 10 days per month to prevent medication overuse headache 1
• Triptans work best when taken early while pain is still mild 4
• Contraindications: History of coronary artery disease, stroke, uncontrolled hypertension, peripheral vascular disease 3

Preventive Pharmacotherapy

Consider preventive treatment when patients experience ≥2 days per month of vestibular symptoms despite optimized acute treatment and lifestyle modifications. 1

First-Line Preventive Medications

Beta Blockers (particularly useful in patients with comorbid hypertension) 1

• Propranolol 80-240 mg/day 1
• Metoprolol, atenolol, or bisoprolol as alternatives 1
• Allow 2-3 months at therapeutic dose before assessing efficacy 1

Topiramate 50-100 mg oral daily 1

• Especially beneficial in obese patients due to weight loss effects 1
• Common adverse effects include cognitive inefficiency, paresthesia, fatigue 1
• Titrate slowly to minimize side effects 5

Candesartan (angiotensin receptor blocker) 1

• First-line option, particularly useful in hypertensive patients 1

Second-Line Preventive Medications

Use when first-line agents fail or are contraindicated. 5

Flunarizine 5-10 mg oral once daily 1

• Effective calcium channel blocker for prevention 1
• Contraindications: Active Parkinsonism, history of extrapyramidal disorders, current depression 1
• Common adverse effects: sedation, weight gain 1

Amitriptyline 10-100 mg oral at night or nortriptyline 1

• Particularly useful for patients with coexisting anxiety or depression 1
• Recent evidence shows nortriptyline at maximum 40 mg effectively alleviates symptoms in 4 weeks 6

Valproic acid 600-1,500 mg oral once daily 1

• Option for men only 1
• Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line: CGRP Monoclonal Antibodies

Consider for refractory cases after failure of first- and second-line agents. 1

• Erenumab 70 or 140 mg subcutaneous once monthly 1
• Fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly 1
• Galcanezumab (monthly subcutaneous) 1
• Eptinezumab 100 or 300 mg intravenous quarterly 1
• Assess efficacy only after 3-6 months of treatment 1

Fourth-Line: OnabotulinumtoxinA

• 155-195 units to 31-39 sites every 12 weeks for chronic migraine with vestibular symptoms 1
• Only FDA-approved therapy for prophylaxis of chronic migraine 1

Non-Pharmacological Adjunctive Therapies

These can be used alongside medications or as stand-alone treatment when medications are contraindicated. 5

• Biobehavioral therapy including relaxation techniques, stress management, and biofeedback 1
• Neuromodulatory devices as adjuncts or stand-alone treatment 1
• Acupuncture has some supporting evidence, though not superior to sham acupuncture 5
• Vestibular rehabilitation may be useful for chronic imbalance between attacks 1

Treatment Duration and Monitoring

• 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
• Encourage headache diaries to track migraine attacks and vestibular episodes 1
• Use validated disability tools such as Migraine Disability Assessment Score and HIT-6 to track treatment response 1

Critical Pitfalls to Avoid

• Never use opioids or barbiturates due to questionable efficacy, considerable adverse effects, and dependency risk 1
• Avoid overuse of acute medications: Limit simple analgesics to fewer than 15 days/month and triptans to fewer than 10 days/month to prevent medication overuse headache 1
• Do not abandon treatment prematurely: Efficacy takes weeks to months to establish 1
• Screen for and manage comorbidities including anxiety, depression, sleep disturbances, and obesity 1
• Rule out other causes of vertigo: 35% of Ménière's disease patients also meet criteria for vestibular migraine; consider noninvasive therapeutic trials before surgical interventions 1

Distinguishing Vestibular Migraine from Ménière's Disease

• Ménière's disease: Documented low-to-mid-frequency sensorineural hearing loss on audiometry, longer duration of vertigo attacks (20 minutes to 12 hours) 1
• Vestibular migraine: Bilateral auditory symptoms more common, mild or absent hearing loss that remains stable over time, prominent photophobia and phonophobia 1