Vestibular Migraine: Treatment and Prognosis

Michael von Brevern, MD; Thomas Lempert, MD


Semin Neurol. 2020;40(1):83-86. 

In This Article

Treatment of Acute Attacks

During acute VM, many patients intuitively avoid head movements and retreat to a quiet place to alleviate their dizziness. Preferred positions vary from sitting to lying on the back or on one side. A short nap during the day or a regular night's sleep may terminate the attack. Pharmacological treatment is justified when attacks of VM are long and severe. Since oral medication will take at least 1 hour before becoming effective, rectal or intravenous drug application may be preferable. Currently, treatment is based primarily on antiemetic/anti-vertiginous antihistamines, which were introduced more than 50 years ago. High-quality evidence on their efficacy in VM is lacking. As histamine modulates neuronal activity at various levels of the vestibular system, antihistaminic drugs are traditionally preferred for nausea due to vestibular dysfunction.[6,7] Commonly used antihistamines include diphenhydramine, dimenhydrinate, and meclizine (Table 1). Typically, their antiemetic effect is more pronounced than their antivertiginous action. Antidopaminergic drugs such as metoclopramide may be similarly useful for VM as their efficacy in migrainous nausea is firmly established.[8] Zolmitriptan showed a nonsignificant trend toward the improvement of acute VM in a small placebo-controlled trial.[9] Patients with long attacks and severe nausea may require hospitalization for intravenous antiemetics and fluid replacement. Methylprednisolone appeared to be effective in a small patient series with prolonged attacks of VM.[10]