What is the diagnosis and management approach for a patient presenting with vestibular headaches?

Vestibular Migraine: Diagnosis and Management

Diagnostic Criteria

Vestibular migraine requires ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, with migraine features present in at least 50% of episodes, after ruling out other causes. 1

Core Vestibular Symptoms to Identify

• Moderate-to-severe vertigo, unsteadiness, balance disturbance, or motion sensitivity that interferes with (moderate) or prohibits (severe) daily activities 2
• Episode duration varies: 30% last minutes, 30% last hours, 30% last days, and 10% last only seconds with repeated head motion 2
• Positional vertigo triggered by head position changes or visual stimulation 2
• Some patients require up to four weeks for complete recovery between episodes 2

Required Migraine Features (≥50% of Episodes)

• Headache characteristics: One-sided location, pulsating quality, moderate-to-severe intensity, or aggravation by routine physical activity 2
• Associated symptoms: Photophobia, phonophobia, visual aura (bright scintillating lights, zigzag lines, or scotomas expanding over 5-20 minutes) 2
• Sensory aura: Paresthesia (pins and needles) affecting face or arm, spreading gradually over ≥5 minutes, lasting 5-60 minutes, then completely resolving 3
• Motion intolerance and susceptibility to motion sickness are common 2

Critical Differential Diagnosis

Distinguish vestibular migraine from other vestibular disorders through specific clinical features:

• Ménière's disease: Documented low-to-mid-frequency sensorineural hearing loss on audiometry, vertigo attacks lasting 20 minutes to 12 hours (longer than typical vestibular migraine), and prominent unilateral tinnitus 1, 2

  • Note: 35% of Ménière's patients also meet vestibular migraine criteria; consider noninvasive therapeutic trials before surgical interventions 1
  • Vestibular migraine typically shows bilateral auditory symptoms with perception of sound processing difficulty rather than true hearing loss, and any hearing loss remains mild and stable over time 1, 2

• BPPV: Lacks migraine/headache components and shows characteristic nystagmus patterns on Dix-Hallpike maneuver 2

• Central causes (stroke, multiple sclerosis): Red flags include downbeating nystagmus on Dix-Hallpike (particularly without torsional component), direction-changing nystagmus without head position changes, gaze-holding nystagmus, or baseline nystagmus without provocative maneuvers 4

  • Additional neurologic findings: dysarthria, dysmetria, dysphagia, sensory/motor loss, or Horner's syndrome suggest brainstem or cerebellar stroke 4

• Critical red flag: Loss of consciousness is NEVER a symptom of vestibular migraine and demands immediate evaluation for alternative diagnoses 2, 3

Management Approach

First-Line: Lifestyle Modifications

Begin with dietary and lifestyle interventions before pharmacotherapy:

• Limit salt/sodium intake, avoid excessive caffeine, alcohol, and nicotine 1
• Eat well-balanced meals, maintain adequate hydration 1
• Establish regular sleep patterns and manage stress 1
• Regular exercise (as effective as pharmacological approaches when combined with other interventions) 1
• Identify and manage allergies 1
• Identify and avoid specific migraine triggers through headache diary 1

Acute Attack Management

For acute vestibular episodes, use vestibular suppressants SHORT-TERM ONLY:

• Meclizine or diphenhydramine for symptom amelioration during acute attacks 1, 5
• Centrally acting anticholinergics (scopolamine) can suppress acute vertigo but have significant side effects 1
• Benzodiazepines may help acute symptoms but carry drug dependence risk 1
• Triptans for concurrent headache (not primarily for vertigo) 1
• Critical pitfall: Do NOT use vestibular suppressants for long-term management 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

Choose based on comorbidities and side effect profile:

• Beta blockers (propranolol, metoprolol, atenolol, bisoprolol): Preferred for patients with comorbid hypertension, but contraindicated in asthma 1, 6

• Topiramate 50-100 mg oral daily: Especially beneficial in obese patients 1

  • Common adverse effects: cognitive inefficiency, paresthesia, fatigue, weight loss 1

• Candesartan (angiotensin receptor blocker): Particularly useful in hypertensive patients 1

Second-Line Preventive Medications

• Flunarizine 5-10 mg oral once daily: Effective when first-line agents fail, but avoid in patients with Parkinsonism or depression 1

• Amitriptyline 10-100 mg oral at night or nortriptyline: Particularly useful for patients with coexisting anxiety or depression 1, 6

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

Third-Line Preventive Medications (Refractory Cases)

• CGRP monoclonal antibodies: 1

  • Erenumab 70 or 140 mg subcutaneous once monthly
  • Fremanezumab 225 mg subcutaneous once monthly or 675 mg quarterly
  • Eptinezumab 100 or 300 mg intravenous quarterly
  • Galcanezumab (dosing per guidelines)

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

Medications to AVOID

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

Treatment Assessment Timeline

• Oral preventive medications: Assess efficacy after 2-3 months at therapeutic dose 1
• CGRP monoclonal antibodies: Assess efficacy after 3-6 months 1
• OnabotulinumtoxinA: Assess efficacy after 6-9 months 1
• Consider pausing treatment after 6-12 months of successful control to determine if preventive therapy can be stopped 1

Medication Overuse Prevention

Limit acute medication use to prevent medication overuse headache:

• Simple analgesics: <15 days/month 1
• Triptans: <10 days/month 1

Non-Pharmacological Adjunctive Therapies

• Biobehavioral therapy: Relaxation techniques, stress management, biofeedback (as effective as pharmacological approaches) 1
• Vestibular rehabilitation: Useful for chronic imbalance between attacks or complications such as loss of confidence in balance or visual dependence 1, 6
• Neuromodulatory devices: Consider as adjuncts or stand-alone treatment when medication is contraindicated 1
• Acupuncture: Some supporting evidence, though not superior to sham acupuncture 1

Patient Education Essentials

• Explain that efficacy is rarely immediate and may take several weeks to months 1
• Emphasize that failure of one preventive treatment does not predict failure of other drug classes 1
• Encourage headache diary to track migraine attacks and vestibular episodes 1
• Use validated disability tools (Migraine Disability Assessment Score, HIT-6) to track treatment response 1
• Simplified dosing schedules improve adherence 1

Comorbidity Management

Identify and manage modifiable risk factors:

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