Medication Management for Vestibular Migraine

DISCLAIMER: This is an educational site for patients, caregivers, and medical providers. This information was accurate as of the date presented. Consult local medical authority or your healthcare provider for specific advice and referrals.

Treatment of Vestibular Migraine

Once a diagnosis of vestibular migraine has occurred, there are many great treatments for it.

Lifestyle

Lifestyle management is always important!

  • Physical activity—Even a walk daily can be helpful. Remember that being in the green (for example, trees, grass, or gardens) exudes positive energy for us.  
  • Diet—Maintain a regular diet and do not skip meals; avoid processed foods and sugar foods. Make sure to eat five fruits and vegetables every day!
  • Sleep—Remember that good rest is critical. We get rid of many chemicals from the day in our sleep.  
  • Stress management—While stress doesn’t cause migraine, it certainly makes it worse, and having healthy ways to deal with stress is important. Individuals with migraine do need “down time” for the brain.

 

Other Options

Vestibular therapy can be helpful alone and also with pharmacologic treatments. See our recommendations on vestibular rehabilitation.

Cognitive behavioral therapy is often as efficacious as preventive medication.  To find a therapist near you, consider going to this website: http://psychologytoday.com.  

Acupuncture has been reported to help some.

Motion sickness medications such as scopolamine (less than 3 days) and meclizine (can cause drowsiness) are often helpful. Similarly, anti-nausea medications such as metoclopramide, ondansetron, promethazine, prochlorperazine can be very helpful. Finally, benzodiazepines like oral diazepamn, lorazepam, and clonazepam are often used, but these can cause sedation and dependence.

 

Pharmacologic Management of Vestibular Migraine

Acute Treatments for Migraine:

Triptans are a mainstay for treatment of migraine. Choosing a triptan that works for you is important. Some triptans have fast onset (injectables and nasal sprays), while some triptans are longer lasting (naratriptan and frovatriptan). Meanwhile, some other triptans interact with our other medications (for example, using propranolol means you need a lower rizatriptan dose). Examples of triptans include the following: 

  • Sumatriptan (injectable, nasal spray, and oral tablet)
  • Rizatriptan (oral); lower dose with propranolol
  • Zolmitriptan (oral and nasal spray)
  • Eletriptan (oral)
  • Almotriptan (oral)
  • Frova triptan (oral)
  • Naratriptan (oral)

Other Acute Treatments:

  • Gepants:  ubrogepant, Rimegepant, Zavegepant (nasal spray)
  • Lasmitidan (can make you sleepy, so do not drive after taking)
  • Meclizine helps acutely and sometimes preventatively
  • Anti-nausea medication, such as metoclopramide, promethazine, ondansetron, or prochlorperazine
  • Dihydroergotamine (nasal spray, SubQ, or IV)

 

Preventative Pharmacologics

Tricyclic antidepressants help with sleep. They are taken at night. Stick to low doses and build up as directed.

  • Amitriptyline
  • Nortriptyline
  • Imipramine

Beta blockers:

  • Propranolol
  • Nadolol
  • Timolol
  • Metoprolol

Calcium channel blockers:

  • Verapamil—sometimes we use verapamil and increase the dose until successful
  • Nifedipine
  • Amlodipine

Anti-convulsants:

  • Topiramate—start low and go slow; caution for women of childbearing years
  • Valproate—same advice
  • Lamotrigine—watch for rashes
  • Zonisamide
  • Gabapentin
  • Pre-gabalin

SSRI and SNRI:

  • Fluoxetine
  • Venlafaxine

Calcitonin Gene Related Peptide (CGRP) antibodies:

  • Erenumab
  • Fremanezumab
  • Galcanezumab—once each month shot to prevent migraine with few side effects  
  • Eptimizumab—an infusion every 3 months

CGRP small molecule inhibitors: 

  • Atogepant
  • Rimegepant—every other day

Onabotulinum Toxin for chronic migraine (that is, migraine that occurs more than 15 days each month)

Supplements: 

  • Magnesium
  • Riboflavin
  • Vitamin D

 

Devices

Some individuals do not want to use medication or want to avoid them. If this is the case, consider the following devices:

  • Supraorbital stimulator: Cefaly device—doesn’t require a prescription and if it is not successful, you get your money back
  • Vagal nerve stimulator
  • Transcutaneous nerve stimulator
  • Transmagnetic stimulation
  • FL41 tint (it's great if you have photophobia or light sensitivity with your vestibular migraine)
  • ICEKAP or equivalent
  • Green light therapy

 

More Information

If you would like more information, please see the following resources:

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