________________________________________________________________________ Dizziness and Vertigo
Symptomatic Treatment of Acute Episodes Acute attacks of vestibular migraine are treated with vestibular suppressants that include benzodiazepines (e.g., clonazepam, lorazepam), antiemetics (e.g., promethazine), antihistamines (e.g., meclizine, dimenhydrinate), and anticholinergic agents (e.g., scopolamine) [163]. Patients with excessive nausea or vomiting may prefer non-oral (e.g., IV, nasal spray, supposito- ries, subcutaneous injections) routes [164]. Abortive Treatment Acute migraine treatment with triptans may offer benefit for patients with vestibular migraine. Sumatriptan was particularly efficacious in improving vertigo; rizatriptan helped prevent motion sickness symptoms. Zolmitriptan probably has little benefit in vestibular migraine [163].
Prophylactic Treatment Treatment with migraine prophylactic medication may be needed when symptoms are frequent or severe and interfere with quality of life [15]. The indications for prophylactic therapy in vestibular migraine mirror those in migraine, which consider the frequency, duration, and disabling nature of attacks [120]. If caffeine and other triggers play a role in inciting episodes, they should be avoided when possible, as avoidance may enhance the efficacy of prophylactic therapy in vestibular migraine [48; 163]. Medications evaluated for prophylactic efficacy in vestibular migraine include antiepileptic drugs (e.g., topiramate, valpro- ate/valproic acid, lamotrigine), beta-adrenergic blockers (e.g., propranolol, metoprolol sustained-release, bisoprolol), calcium channel blockers (e.g., flunarizine, verapamil extended-release, cinnarizine), and antidepressants (e.g., venlafaxine, nortripty- line, imipramine, amitriptyline). Prophylactic recommenda- tions have been based on available evidence, attack frequency, and clinical profile ( Table 3 ).
PROPHYLACTIC PHARMACOTHERAPY FOR VESTIBULAR MIGRAINE
Characteristic
Recommended Agent(s)
By Available Evidence High-quality evidence of efficacy
Topiramate 25–100 mg/day Valproate 300–900 mg/day Metoprolol sustained-release 50–200 mg/day
Moderate-quality evidence of efficacy
Propranolol 40–240 mg/day Flunarizine 5–10 mg/day
Low-to-moderate-quality evidence of efficacy
Amitriptyline 50–100 mg/day Verapamil extended-release 120–360 mg/day Cinnarizine 37.5–75 mg/day
Lowest-quality evidence of efficacy By Attack Frequency Three or more attacks per month or long-lasting/disabling attacks
Acetazolamide 250–750 mg/day
First-line: Propranolol 80–240 mg/day, metoprolol 50–200 mg/day, or bisoprolol 5–10 mg/day Second-line: Flunarizine 5–10 mg/day Third-line: Topiramate 25–100 mg/day or valproic acid 500–600 mg/day First-line: Topiramate 25–100 mg/day Second-line: A trial of onabotulinum toxin type A (155 MU) is reasonable but unlikely to improve vestibular symptoms Verapamil 120–240 mg/day (well-tolerated medication with good efficacy) Alternative: Topiramate 50–200 mg/day (often effective) Lamotrigine 25–100 mg/day to reduce the frequency of vertigo episodes; less effective in reducing headache frequency Combination of two or three migraine prophylactic medications from different drug classes Consider zonisamide or acetazolamide
Fifteen migraine attacks or more than eight migraine headaches per month for longer than three months By Clinical Profile Prominent nausea and/or headaches and less prominent or minimal anxiety Prominent vertigo or dizziness, less frequent migraine headache
Severe vestibular migraine
Source: [15; 120; 164; 165; 166; 167]
Table 3
69
Book Code: ANCCTX2027
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