Journal of Clinical Outcomes Management. 2015 October;22(10)
References
Simple analgesics, such as paracetamol and nonsteroidal anti-inflammatory drugs (NSAIDs), have been found to be helpful in acute VM attacks in observational studies. Bikhazi performed a survey of patients presenting to a headache clinic with vestibular symptoms and found that simple analgesics were valued by patients as effective symptomatic treatment, but were not considered as effective as triptans [59]. Doses of simple analgesics are listed in Table 2. Soluble formulations are preferable due to faster absorption and speed of onset. Opioids should be avoided in acute attacks of VM given the risk of developing opioid overuse headache [55].
Migraine Prophylaxis in Vestibular Migraine
Preventive migraine medications include beta-blockers, TCAs, flunarizine, and antiepileptic medications ( Table 3 ). In the absence of head-to-head comparison studies, no single prophylactic agent appears to be preferable. Expected side effects will influence the selection of the drug. Treatment response should be evaluated after 2 to 3 months. A greater than 50% reduction in attack frequency and severity would be considered an excellent therapeutic outcome.
TCAs remain a popular choice of migraine prophylaxis amongst neurootologists because of its additional effects on comorbid affective symptoms. We recommend that the starting dose of either amitriptyline or nortriptyline should be between 5 to 10 mg daily at night, slowly uptitrated to response over several weeks up to a maximum of 100 mg at night. Interval electrocardiography should be performed to monitor for prolongation of the QTc interval. A retrospective chart review found 46% of VM patients (by Neuhauser criteria) reported a reduction in dizziness after nortriptyline administration up to 75 mg daily [62]. However, the current evidence is limited to observational studies [59,62–64].
The evidence for beta-blockers is limited in VM but anecdotally has been useful for patients with frequent episodic migraine [59,63,64]. Recommended starting and maintenance doses are listed in Table 3. Furthermore, propranolol can be used in patients with depression [65,66]. Heart rate and electrocardiography should be monitored during dose escalation. Beta-blockers should be avoided in asthmatics. Commonly reported adverse events include cold, extremities reduced exercise tolerance and dizziness [53].
Flunarizine, a calcium channel blocker widely used in migraine [67,68] and vestibular conditions [69], was recently studied in a RCT of 12 weeks' duration for prophylaxis of migrainous vertigo (Neuhauser criteria) in 48 patients [70]. Although flunarizine 10 mg daily did not result in improved headache frequency and severity compared to the control arm, there was a significant improvement in vertigo severity. The most commonly reported side effects of flunarizine are weight gain and somnolence, both of which are minimal or infrequent. Verapamil is another calcium channel blocker that may be helpful but has major limiting adverse effects are bradycardia, constipation and peripheral edema [53].
Pizotifen, a serotonin antagonist, is one of the most well tolerated prophylaxis agents from our experience, however some patients do not adhere to treatment due to drowsiness or weight gain, as evidenced in retrospective case studies [64].
Topiramate with an average daily dose of 100 mg has reported positive results in a prospective observational study of ten patients with VM with auditory symptoms [71]. Nine of 10 patients reported no symptoms after follow-up period of up to sixteen months. The recommended dose is listed in Table 3. Common side effects include distal paresthesias, reduced ability to concentrate and drowsiness [53]. Sodium valproate has been anecdotally effective [59] and is usually well tolerated especially when starting at a low dose of 200 mg at night, slowly titrated to 1200 mg in 2 divided doses. Liver function and full blood evaluation should be monitored on a periodic basis [53].
