Published online: 30.12.

2019

Vestibular Migraine: Treatment and Prognosis

Michael von Brevern, MD1 Thomas Lempert, MD2

1 Neurologisches Zentrum, Berlin, Germany Address for correspondence Michael von Brevern, MD,
2 Department of Neurology, Schlosspark-Klinik, Berlin, Germany Neurologisches Zentrum, Clayallee 177, Berlin, 14195, Germany
(e-mail: von.brevern@mail.de).
Semin Neurol

Abstract Treatment of vestibular migraine currently lacks a firm scientific basis, as high quality
randomized controlled trials are not available. Therefore, recommendations are largely
borrowed from the migraine sphere. The first therapeutic step is explanation and
reassurance. Many patients do not need pharmacological treatment, as attacks may be
infrequent and tolerable. Acute attacks can be ameliorated in some patients with
Keywords antiemetic drugs such as diphenhydramine, meclizine, and metoclopramide. Frequent
► migraine attacks may warrant pharmacological prophylaxis with metoprolol, amitriptyline,

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► vertigo topiramate, valproic acid, or flunarizine. Nonpharmacological measures including
► vestibular migraine regular exercise, relaxation techniques, stress management, and biofeedback may
► treatment be similarly effective and can be combined with a pharmacological approach. Limited
► migrainous vertigo data indicate that the prognosis appears to be less favorable for vestibular migraine
► dizziness than for migraine headaches.

Vestibular migraine (VM) is probably as old as mankind, but
systematic research of the condition only started in the last
three decades. Treatments of VM have not been evaluated by
sufficiently large and well-designed controlled trials. Instead,
numerous retrospective case series have been published that
yielded positive outcomes for almost any taken approach.
However, before-and-after comparisons are not suitable to
measure treatment effects as they are contaminated by spon-
taneous improvement, placebo effect, and potentially biased
evaluations by unblinded investigators. In the lack of firm
evidence, current recommendations are largely borrowed
from the therapeutic armory of migraine headache, which
has a more solid scientific basis.
Counseling and Reassurance
First of all, patients need to be assured that VM is a bother-
some but harmless condition that comes and goes, just like
bad weather. Patients tend to see a neurologist when attacks
are particularly frequent and severe. Thus, spontaneous
fluctuations of disease activity will improve most of them
over time. This “regression to the mean” effect and several
therapeutic options justify conveying a cautiously optimistic
prognosis.
A useful concept explains migraine as a permanent hyper-
sensitivity of the senses and the nervous system, which peaks
during attacks but may persist in the interval. This is why some
patients may experience less intense symptoms even in
between attacks, such as head-motion and visually induced
dizziness, fatigability, and stress intolerance. Individual
migraine triggers such as excessive stress, lack of sleep, food,
and fluid may then lead to acute attacks. You may encourage
your patients to reflect on these vulnerabilities and triggers to
develop a sense of effective self-care, which includes regular
sleeping and eating habits, taking breaks during work, and
exercising regularly (for details on nonpharmacological
migraine prophylaxis, see the next section). Comorbid psychi-
atric disorders, particularly anxiety and depression, occur in
more than half of VM patients and may require referral to a
psychiatrist or psychotherapist.1
Does Your Patient Need Pharmacological
Treatment?
Patients’ expectations regarding drug treatment and doctors’
actual prescriptions may be incongruous.2 Many patients
either do not expect or do not require medication. Some of
them rather need to be relieved from their fear of a tumor or

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Vestibular Migraine von Brevern, Lempert
an imminent stroke. Others may have short or rare attacks,
which argues against acute or prophylactic treatment, and
still others do not like to take medication at all. On the other
hand, both patients and doctors tend to overestimate the
efficacy of treatments and underestimate their harms.3,4 As a
consequence, shared decision-making on the treatment of
VM is based on discussing the expectations, therapeutic
options, and limitations of the various approaches. Interest-
ingly, only 36% of patients with VM who knew about their
diagnosis and were informed about treatment options had
tried migraine prophylaxis when they were reevaluated after
a mean of 9 years. Only 13% were still on prophylactic
medication.5
Treatment of Acute Attacks
During acute VM, many patients intuitively avoid head move-
ments 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 justi-
fied 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 tradi-
tionally 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 antivertigi-
nous 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 nonsig-
nificant 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 antiemet-
ics and fluid replacement. Methylprednisolone appeared to be
effective in a small patient series with prolonged attacks of
VM.10
Pharmacological Prophylaxis
In patients with frequent and disabling attacks of VM, pharma-
cological prophylaxis should be considered. Migraine prophy-
Table 1 Antiemetics for the treatment of acute vestibular migraine
Drug Dose
Diphenhydramine 25–50 mg every 6 h (oral, intravenous)
Meclizine 25–50 mg every 6 h
Dimenhydrinate 50–100 mg every 6 h (oral, rectal, or intravenous)
Metoclopramide 10 mg every 4 h (oral, rectal, or intravenous)
Seminars in Neurology
laxis 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 antide-
pressants (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 A12 and anti-
bodies 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,
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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 venlafax-
ine,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
Common side effects
Blurred vision, sedation, exacerbation of glaucoma,
urinary retention
See above
See above
Extrapyramidal effects, hypotension,
QT prolongation, sedation

Table 2 Prophylactic treatment of vestibular migraine in the
absence of firm evidence
Drug Daily dose Common side effects
Propranolol 40–240 mg Fatigue, hypotension,
impotence, depression,
bronchial constriction
Metoprolol 50–200 mg See above
Topiramate 50–100 mg Paresthesia, somnolence,
weight loss, cognitive
dysfunction
Valproic acid 600 mg Weight gain, sedation,
fetal malformation
Flunarizine 5–10 mg Weight gain, sedation,
depression
Amitriptyline 25–75 mg Sedation, orthostatic
hypotension, dry mouth,
weight gain, constipation,
urinary retention,
conduction block
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 prophy-
lactic 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.
Nonpharmacological Prophylaxis
Many patients with VM are unwilling to take daily medica-
tion and instead prefer nonpharmacological interventions.
One out of two U.S. adults with migraine use complementary
and alternative therapies.33 Behavioral interventions includ-
ing relaxation training, biofeedback training, and stress
management training (i.e., cognitive behavioral therapy)
have shown similar and clinically meaningful improvement
compared with medications in the prevention of migraine
headache.34 Furthermore, a combination of pharmacological
and behavioral migraine prophylaxis is more effective than
either intervention employed singularly.35 Dissemination of
these therapies in everyday clinical practice is poor, but
advances in internet-based delivery platforms may provide
better access to self-management strategies.34 Although
behavioral interventions have not been evaluated in VM, it
is likely that they are also effective in this migraine variant,
which is often afflicted by psychiatric comorbidity, most
commonly anxiety and somatoform disorders.36
Vestibular Migraine von Brevern, Lempert
There is limited evidence for the effectiveness of aerobic
exercise,37 acupuncture,38 and nutraceuticals39 such as mag-
nesium, riboflavin, and coenzyme Q10 for the prevention of
migraine headache. Regular exercise seems to reduce symp-
toms in VM,40 but other interventions have not been evalu-
ated in patients with VM.
Vestibular Rehabilitation
A course of vestibular rehabilitation can be tried in patients with
persistent dizziness and imbalance in between attacks, whereas
prevention of future attacks is not to be expected. Several
studies reported positive outcomes, but the mixed quality of
the available trials precludes an evidence-based recommenda-
tion for this approach.41
Prognosis
Few studies have dealt with the prognosis of VM. A follow-up
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study at 9 years after initial diagnosis found that almost 90% of
61 patients still suffered from recurrent vertigo (mean age at
follow-up: 55 years).5 Frequency of vertigo was reduced in 56%,
increased in 29%, and unchanged in 16%. All but one patient still
had migraine headaches. Both cochlear symptoms during
attacks (49%) and mild bilateral sensorineural hearing loss
(18%) with a downsloping pattern on audiometry were more
common on follow-up than at the initial presentation. Mild
ocular motor abnormalities in the asymptomatic interval,
including central positional nystagmus, defective smooth pur-
suit, and impaired vestibulo-ocular reflex suppression, become
more common during the course of the disease.5,41 Psychiatric
disorders complicate the course of VM in more than 50% of
patients and require individualized treatment.36,42 Bilateral
vestibulopathy may rarely develop in the course of VM.43,44
Conclusion
Appropriate treatment of VM often requires a conversation
with the patient. Factors to consider include the patient’s goals,
reasonable expectations, the impact symptoms are having on
the quality of life, the presence of comorbidities, and possible
medication side effects. For those in need of pharmacological
prophylactic medication, at present we lack quality clinical
trials to guide treatment decisions and therefore must borrow
from our knowledge of the treatment of migraine headache.
Future studies, it may be hoped, will shed light on the
treatment efficacy of medications to treat VM.
Conflict of Interest
None.
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