Vestibular Migraine: Treatment and Prognosis

Michael von Brevern, MD; Thomas Lempert, MD


Semin Neurol. 2020;40(1):83-86. 

In This Article

Pharmacological Prophylaxis

In patients with frequent and disabling attacks of VM, pharmacological prophylaxis should be considered. Migraine prophylaxis aims to reduce the frequency, severity, and duration of attacks. Most pharmacological agents that are recommended for the prophylaxis of VM are derived from the treatment of migraine headache. There is high-quality evidence for several drugs in the prevention of migraine headache, including β-blockers (metoprolol and propranolol), antiepileptics (topiramate and valproic acid), calcium channel antagonists (flunarizine; not available in the United States), and antidepressants (amitriptyline). Thus, these agents are first-line drugs recommended almost unequivocally by American, Canadian, and European guidelines.[11] Furthermore, there are effective treatment options for the prevention of migraine that are administered nonorally, namely botulinum toxin A[12] and antibodies against the calcitonin gene-related peptide receptor or its ligand,[13] but there is no experience with these agents in VM. The efficacy of migraine prophylactic drugs is only moderate: seven people would need to be treated to achieve a 50% reduction in headache burden in one patient.[14] Furthermore, patient tolerance of drugs is limited by unfavorable side effects, with drowsiness being the most common.[14] As a consequence of adverse effects and limited efficacy, adherence to oral migraine prophylaxis is poor,[15] dropping to approximately 20% after 6 months.[16]

Unfortunately, evidence from well-conducted treatment trials of pharmacological prevention of VM is lacking.[17,18] There are numerous retrospective cohort studies and open-label trials involving prophylactic medical treatment of VM, with various agents being recommended from guidelines for migraine headache.[19–26] Furthermore, several case series reported treatment effects of less established prophylactic migraine medications including pizotifen,[26] magnesium,[21] butterbur root extract,[21] and drugs usually not often used in migraine such as carbamazepine,[26] lamotrigine,[27] venlafaxine,[24] acetazolamide,[28] cinnarizine,[29] and a combination of cinnarizine and dimenhydrinate.[30] The fact that virtually all of these studies report benefit from oral prophylaxis of VM raises suspicion that what appears to be pharmacological efficacy might be rather due to the placebo effect and spontaneous remission. Of note, the placebo response in studies with pharmacological therapies for the prevention of migraine headaches ranges between 14 and 31%.[31]

In migraine headache, there is no firm evidence that any of the recommended preventive agents is more effective than others,[14,32] and the same accounts for the pharmacological prophylaxis of VM.[25] Thus, a drug is chosen primarily on the basis of coincidental and comorbid conditions and expected side effects. As a rule, drugs licensed for migraine prophylaxis with high evidence for this indication should be prescribed (Table 2). In patients with hypertension, a β-blocker is usually the first choice. The use of several drugs can be limited by weight gain (flunarizine, valproate, amitriptyline, pizotifen). The medication is started at a low dose and then increased slowly. Patients should monitor their frequency and severity of episodes of vertigo and dizziness (and headache if applicable) in a diary, ideally before starting a drug and thereafter. It is essential to evaluate treatment response after 2 to 3 months. A 50% reduction in attack frequency is a realistic goal. A prophylactic drug that does not demonstrate efficacy in an individual patient should be stopped and replaced by another agent. There is no consensus on the duration of prophylactic drug treatment. If VM is well controlled for at least 6 months, medication can be slowly tapered and, if possible, discontinued.