Management of vestibular migraine

Abstract

Vestibular migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo. The duration of attacks varies from seconds to days, usually lasting minutes to hours, and they mostly occur independently of headaches. Long-lasting individual attacks are treated with generic antivertiginous and antiemetic drugs. Specific antimigraine drugs are unlikely to be very effective for rescue. The mainstay of the management of vestibular migraine is prophylactic medication. To date, there are no controlled trials available; the body of knowledge builds on case series and retrospective or observational studies. Most drugs are also used for the prevention of migraine headaches. The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established. Nonpharmacological measures such as diet, sleep, hygiene and avoidance of triggers are recommended as they are for migraine. Vestibular rehabilitation might be useful when there are complications such as loss of confidence in balance or visual dependence.

A novel locus for episodic ataxia:UBR4 the likely candidate

“…20,21 Clonazepam is not typically used in EA; however, it has been used successfully in vestibular migraine, a condition suspected to be due to channelopathy in some cases. 22 It increases the frequency of chloride ion channel opening, enhancing the inhibitory effect of GABA at the GABAa receptor; 23 however, it has multiple other central effects. Benzodiazepines have also been shown to have an inhibitory effect on voltage-dependant calcium channels, 24 which may be relevant in the setting of the UBR4 genetic variant that we have described in this family.…”

The Role of Lifestyle Modifications in the Management of Migraine Associated Vertigo

“…Migraine is considered to be the second most common cause of vertigo and the most common cause of spontaneous episodic vertigo [2]. Migraine (14%) and vertigo (10%) are common disorders, affecting the general population.…”

“…A certain trigger will not induce a migraine in every person. Also in a single migraine sufferer, a trigger may not cause a migraine every time [2,8]. Excessive amounts of nuts intake (nuts, peanuts, pistachios, sunflower seeds)…”

“…The criteria for inclusion in the study are as follows: [1] diagnosis of MAV based on the adopted criteria used by Murofushi et al [4] which was processed on the basis of Neuhauser's [5] and Brantberg's criteria [6]. This included presence of moderate to severe, recurrent, or episodic vestibular symptoms; migraine headache according to the International Headaches Society (IHS) criteria, synchronization of vertigo attack with migraine (at least one of migranious headache, photophobia, phonophobia, visual or other auras occurring during at least two vertiginous attack), absence of associated unilateral hearing loss, or other disease causing vertiginous attack [2] information on pathophysiology [3] differential diagnosis of peripheral vestibular disorder. All patients were asked for possible MAV triggers.…”

“…Like migraine headaches, there are some similar triggers include stress, sleep deprivation, and hormonal changes in MAV. Non-pharmacological treatments such as dietary changes, regular sufficient sleep, reduction of stress, comfortable exercise habit and avoidance of other triggers are recommended as they are for migraine [2][3]. Most drugs are also used for the prevention of MAV [1].…”