Vestibular migraine is a disabling health condition characterized by severe, recurrent attacks of vertigo.
A Cochrane review assessed the benefits and potential harms of medications used to try to prevent these attacks.
Key Facts:
- Only 3 small studies, with 209 participants in total, were identified that compared medications to placebo or no treatment
- The studies provided low or very low certainty evidence on the effects of beta-blockers (metoprolol) or calcium channel blockers (flunarizine)
- None of the studies assessed effects beyond 6 months of treatment
- Further research is needed to establish whether pharmacological treatments can prevent vestibular migraine attacks
Source: Cochrane Database Syst Rev. (2023)
What is Vestibular Migraine?
Vestibular migraine is a form of migraine where severe dizziness or vertigo is the main symptom.
Attacks are often accompanied by other migraine features like headaches, light sensitivity, sound sensitivity, nausea and visual disturbances.
This disabling health condition affects around 1% of the population.
Episodes are unpredictable, lasting anywhere from 5 minutes up to 3 days.
Their severity can make normal daily activities difficult or impossible.
As a result, quality of life is considerably reduced for many people with vestibular migraine.
Diagnosing the disorder can be challenging due to overlapping symptoms with other balance-related conditions and migraine headaches alone.
International consensus criteria now exist to help classify cases as either “definite vestibular migraine” or “probable vestibular migraine.”
Treatments aim to stop acute vestibular migraine attacks or prevent them from happening. preventative options
Typically draw from medications used for migraine headaches, based on presumed similarities in underlying disease processes.
However, there are currently no evidence-backed treatment guidelines for healthcare providers or patients to follow.
Vestibular Migraine Prevention with Medications (Evidence Review)
Reviewers searched medical literature databases for relevant studies published up to September 2022.
They included randomized controlled trials comparing oral medications to placebo or no treatment in adults with vestibular migraine.
Outcomes of interest were the number of participants with attack improvement, numeric symptom scores, serious side effects and quality of life.
The quality of evidence for each outcome was assessed using the GRADE approach, which judges risk of bias, consistency, directness, precision and publication bias.
Only 3 eligible studies with 209 total participants were identified:
- Bayer 2019: 130 people treated with either 95mg of metoprolol succinate or placebo pill once daily for 6 months
- Lepcha 2014 & Yuan 2016: 79 people treated with either 10mg flunarizine or nothing once daily for 3 months
All evidence was rated low or very low certainty based on study limitations, imprecision due to small numbers and wide effect estimate ranges.
Metoprolol
- May make little or no difference in attack frequency at 3-6 months
- Unclear if there is any difference in serious side effects
- Insufficient evidence for other outcomes
Flunarizine
- May improve vertigo severity at < 3 months
- May slightly reduce attack frequency at 3-6 months
- Unclear effects for other efficacy and safety outcomes
No studies assessed antiepileptics, antidepressants, diuretics, calcitonin gene-related peptide inhibitors, botulinum toxin injections or hormonal therapies.
Evidence Limitations for Medications in Vestibular Migraine Prevention
The review highlights several limitations of the small evidence base:
- Only evaluates 2 medication types, both possibly unavailable depending where you live
- Applies largely to people experiencing ≥ 2 attacks per month
- No data beyond 6 months treatment duration
- Outcomes and measurement tools differed across studies
- Safety evaluations lacked detail on common medication side effects
Concerns also exist around included study quality, use of unvalidated symptom scales and current lack of consensus on core outcomes for vestibular migraine trials.
What do the findings mean for clinical prophylaxis of vestibular migraine?
There is presently not enough evidence for strong conclusions on any pharmacological options for preventing vestibular migraine attacks.
The few studies only provide low or very low certainty around potential symptom effects of metoprolol or flunarizine. Safety remains uncertain.
People considering medications for vestibular migraine should know that none have an established evidence base demonstrating attack prevention or tolerability.
More research clearly needed to clarify this situation for all treatment options.
Current Preventative & Treatments for Vestibular Migraine
Pharmacological Medications
- Antidepressants: Certain antidepressants, especially tricyclics like amitriptyline and SSRIs (Selective Serotonin Reuptake Inhibitors), are often prescribed for migraine prophylaxis and may be beneficial for some patients with vestibular migraine.
- Antiepileptic Drugs: Medications like topiramate and valproate, used to control seizures, have also been used to prevent migraines, including vestibular types, due to their stabilizing effect on nerve cells.
- Beta-blockers and Calcium Channel Blockers: While the evidence from the Cochrane review was limited, these medications, traditionally used for high blood pressure and heart conditions, have long been used in preventing various types of migraines due to their effect on blood flow and neuronal stability.
Non-Pharmacological Interventions
- Lifestyle Adjustments: Regular sleep patterns, hydration, stress reduction, and avoidance of known personal migraine triggers (like certain foods or bright lights) are generally recommended.
- Dietary Changes: Some people find relief by adhering to a migraine diet that eliminates known triggers such as chocolate, cheese, and red wine. Others may benefit from magnesium supplements or a diet high in foods that contain magnesium.
- Cognitive Behavioral Therapy (CBT): CBT and other behavioral therapies can help manage the stress and anxiety that may accompany or exacerbate vestibular migraine attacks.
Alternative & Complementary Treatments
- Acupuncture: Some patients report reduced frequency and severity of migraine attacks, including vestibular types, after undergoing acupuncture.
- Biofeedback and Relaxation Techniques: These methods focus on reducing stress and managing physical symptoms through mental control, and they can be particularly beneficial in conditions influenced by stress.
- Herbal Supplements: Feverfew and butterbur are two herbs that some believe can reduce the frequency of migraine attacks, though they should be used with caution and under supervision due to potential side effects and interactions.
Innovative & Emerging Approaches
- Neuromodulation Devices: Devices that use electrical or magnetic stimulation on certain parts of the head or neck are being explored for various types of migraines, including vestibular migraine.
- Calcitonin Gene-Related Peptide (CGRP) Inhibitors: A new class of drugs shown to be effective in preventing migraine attacks in some individuals. CGRP is a molecule involved in causing migraine pain.
- Botox Injections: OnabotulinumtoxinA (Botox) injections are FDA-approved for chronic migraines and might be considered in some cases of severe, frequent vestibular migraines.
Considerations & Future Directions
- Individualized Treatment: Given the varied response to treatments, an individualized approach is essential. What works for one patient may not work for another, and it often takes time to find the most effective strategy.
- Long-Term Management: Vestibular migraine is typically a chronic condition, and long-term treatment plans, including regular follow-up and adjustment of strategies, are crucial.
- Research Gaps: As highlighted by the Cochrane review, there’s a significant need for more extensive, high-quality research to establish the safety and efficacy of current and emerging treatments for vestibular migraine.
While the Cochrane review indicates a lack of strong evidence for specific pharmacological treatments, it’s clear that a multifaceted approach, often combining medication with lifestyle changes and possibly alternative treatments, is currently used to manage vestibular migraine.
Continuous research, patient education, and individualized care remain key to improving the lives of those affected by this challenging condition.
Future Research of Vestibular Migraine (Questions)
The review highlights several areas needing better evidence from sufficiently large, rigorous studies:
- How safe and effective are medications used specifically for vestibular migraine or other migraine forms compared to placebo or nothing? What treatment regimes and doses perform optimally?
- Do preventative benefits continue beyond 6 months treatment duration? Does efficacy depend on medication type or vestibular migraine features like attack frequency, migraine subtype or time since diagnosis?
- What measurement tools best capture symptom changes and quality of life impacts of greatest importance to people with vestibular migraine? What consensus core outcomes should be reported in all trials?
Addressing these unknowns will provide patients and doctors the information they require choosing wisely between available therapies.
Researchers are now tasked with rising to meet the needs this neglected condition through well-designed studies on existing and novel treatment options for vestibular migraine attacks.
In summary, this Cochrane review reveals a concerning lack of reliable evidence supporting any pharmacological treatments to prevent debilitating vertigo attacks due to vestibular migraine.
Additional well-designed comparative trials on medications in current off-label use are clearly needed, along with real-world data clarifying longer term efficacy, safety and impacts on quality of life for people with this disorder.
References
- Study: Pharmacological interventions for prophylaxis of vestibular migraine
- Authors: Webster et al. (2023)
