What is the recommended treatment approach for a patient with vestibular migraine, including acute and preventive therapies?

Treatment of Vestibular Migraine

Vestibular migraine requires a multimodal treatment strategy combining lifestyle modifications as first-line intervention, followed by preventive pharmacotherapy when symptoms occur ≥2 days per month, with acute medications reserved for severe attacks and limited to ≤2 days per week to prevent medication-overuse headache. 1

Diagnostic Confirmation Before Treatment

Before initiating therapy, confirm the diagnosis by documenting:

• ≥5 episodes of vestibular symptoms (vertigo, head-motion intolerance, positional dizziness) lasting 5 minutes to 72 hours 1
• Temporal association between vestibular symptoms and migrainous features (headache, photophobia, phonophobia, visual aura) 2, 3
• Exclusion of central causes including stroke, multiple sclerosis, or other secondary etiologies by ruling out red flags: downbeating nystagmus on Dix-Hallpike, direction-changing nystagmus, gaze-holding nystagmus, dysarthria, dysmetria, dysphagia, or focal sensory/motor deficits 1

Critical distinction from Ménière's disease: Vestibular migraine typically shows stable or absent hearing loss (versus fluctuating low-to-mid-frequency sensorineural hearing loss on audiometry), bilateral auditory symptoms more common than unilateral, and less prominent tinnitus; however, 35% of Ménière's patients also meet criteria for vestibular migraine 1

First-Line Treatment: Lifestyle Modifications

Begin with dietary and lifestyle interventions before pharmacotherapy, as these form the foundation of vestibular migraine management: 1

• Limit salt/sodium intake to reduce fluid retention 1
• Avoid excessive caffeine, alcohol, and nicotine as vestibular triggers 1
• Maintain regular sleep schedule (sleep deprivation is a common precipitant) 1
• Establish consistent meal patterns with adequate hydration 1
• Implement stress management techniques including relaxation training and biofeedback 1
• Regular aerobic exercise (as effective as pharmacological approaches when combined with other interventions) 1
• Identify and manage allergies that may exacerbate symptoms 1

Patient education is essential to improve understanding of the biological basis of the disorder and adherence to treatment plans 1

Acute Management of Vestibular Attacks

Symptomatic Relief During Attacks

Vestibular suppressants may be offered for acute attacks but should not be used for long-term management: 1

• Meclizine or diphenhydramine can ameliorate acute vestibular symptoms 1
• Benzodiazepines (e.g., lorazepam) may help with acute symptoms but carry risk of drug dependence 1
• Scopolamine (centrally acting anticholinergic) can suppress acute vertigo attacks, though with significant side effects 1

Antiemetic medications for nausea/vomiting during attacks: 1

• Metoclopramide 10 mg (oral or IV) provides both antiemetic and direct analgesic effects 4
• Prochlorperazine 10 mg (oral or IV) is comparable in efficacy to metoclopramide 4

Triptans can be used to treat concurrent headache during vestibular migraine attacks: 1

• Sumatriptan 50-100 mg oral or 6 mg subcutaneous for moderate-to-severe headache 1, 4
• Rizatriptan 10 mg (fastest oral triptan, reaching peak in 60-90 minutes) 4
• Intranasal sumatriptan 5-20 mg when significant nausea/vomiting is present 4

Critical frequency limitation: Limit all acute medications to ≤2 days per week (≈10 days/month) to prevent medication-overuse headache 1, 4

Preventive Pharmacotherapy

Indications for preventive therapy: 1

• Vestibular symptoms occurring ≥2 days per month despite optimized acute treatment 1
• Significant disability or quality-of-life impairment from attacks 1
• Contraindication to or failure of acute treatments 1

First-Line Preventive Medications

Beta-blockers (particularly for patients with comorbid hypertension): 1

• Propranolol 80-240 mg/day (FDA-approved, strong RCT evidence) 1
• Metoprolol, atenolol, or bisoprolol (moderate evidence) 1

Topiramate 50-100 mg oral daily (especially beneficial in obese patients): 1

• Common adverse effects: cognitive inefficiency, paresthesia, fatigue, weight loss 1
• Start low and titrate slowly 1

Candesartan (angiotensin receptor blocker, particularly useful in hypertensive patients): 1

Second-Line Preventive Medications

Flunarizine 5-10 mg oral once daily (calcium channel blocker): 5, 1

• Should be considered the preferred preventive option when first-line agents fail based on two randomized clinical trials 1
• Typical dose: 10 mg/day 5
• Adverse effects: sedation, weight gain, abdominal pain 5
• Avoid in patients with Parkinsonism or depression 1
• Duration of vestibular symptoms appears to increase benefit, with 80.9% of patients showing improvement when given sufficient time 5

Amitriptyline 10-100 mg oral at night or nortriptyline (particularly useful for patients with coexisting anxiety or depression): 1

Valproic acid 600-1,500 mg oral once daily (for men only): 1

• Absolutely contraindicated in women of childbearing potential due to teratogenicity 1

Third-Line Preventive Medications (Refractory Cases)

CGRP monoclonal antibodies when first- and second-line agents have failed: 1

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

OnabotulinumtoxinA 155-195 units to 31-39 sites every 12 weeks may be considered for chronic migraine with vestibular symptoms (only FDA-approved therapy for chronic migraine prophylaxis): 1

• Assess efficacy after 6-9 months 1

Treatment Duration and Assessment

Trial period for oral preventive medications: 5, 1

• Start dose low and titrate slowly until clinical benefits are achieved or adverse effects limit increase 5
• Assess efficacy after 2-3 months at therapeutic dose 5, 1
• Use visual analog scales (VAS) for dizziness and headache to quantify improvement 5
• Avoid changing medication before completing adequate trial period of 2-3 months 5

After successful control: Consider pausing treatment after 6-12 months to determine if preventive therapy can be stopped 1

Emphasize to patients: 1

• Efficacy is rarely observed immediately and may take several weeks to months 1
• Failure of one preventive treatment does not predict failure of other drug classes 1
• Treatment adherence improves with simplified dosing schedules 1

Non-Pharmacological Approaches

Biobehavioral therapy (relaxation techniques, stress management, biofeedback) can be as effective as pharmacological approaches and should be combined with medication: 1

Vestibular rehabilitation may be useful for chronic imbalance between attacks: 1

Neuromodulatory devices can be considered as adjuncts or stand-alone treatment when medication is contraindicated: 1

Acupuncture has some supporting evidence for prevention, though not superior to sham acupuncture: 1

Medications to Absolutely Avoid

Oral ergot alkaloids, opioids, and barbiturates should be avoided due to questionable efficacy with considerable adverse effects and dependency risk: 1

Positive pressure therapy should not be prescribed for vestibular migraine: 6

Monitoring and Follow-Up

Track treatment response using: 1

• Headache diary to monitor migraine attacks and vestibular episodes 1
• Validated disability tools such as Migraine Disability Assessment Score and HIT-6 1

Identify and manage modifiable risk factors: 1

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

Common Pitfalls to Avoid

Failure to recognize and manage comorbidities such as anxiety, depression, and sleep disturbances: 1

Overuse of acute medications leading to medication-overuse headache: 1

Abandoning treatment prematurely before efficacy can be established (takes weeks to months): 1

Inadequate follow-up to assess treatment response: 1

Overuse of vestibular suppressant medications for long-term management (should be reserved for acute attacks only): 1