Botulinum Toxin Use in Vestibular Migraine: Guideline‑Based Recommendations

Indications for OnabotulinumtoxinA

OnabotulinumtoxinA is recommended only for chronic migraine (CM), defined as ≥ 15 headache days per month, with a weak‑for recommendation showing an average reduction of 1.8 headache days per month compared with placebo【@1】.

The same guidelines issue a weak‑against recommendation for onabotulinumtoxinA in episodic migraine (EM) because it has not demonstrated a reduction in monthly migraine or headache days, and the frequency of adverse events favours placebo【@1】【@2】.
Vestibular migraine is not listed as a separate indication for botulinum toxin therapy in major headache guidelines, implying that the recommendations for EM apply to it【@1】【@2】【@3】【@4】.
Since vestibular migraine typically presents as episodic vertigo attacks with migraine features, the guideline’s recommendation against botulinum toxin for EM extends to most vestibular‑migraine patients【@1】【@2】.

Consider onabotulinumtoxinA only when the patient meets chronic migraine criteria (≥ 15 headache days per month)【@1】.
Consider only after failure of multiple first‑line preventive therapies (e.g., ARBs, CGRP antibodies, beta‑blockers, topiramate)【@2】.
Documented chronic headache pattern (not merely episodic vestibular attacks) is required before Botox can be contemplated【@1】【@2】.

Angiotensin‑II receptor blockers (ARBs) such as candesartan or telmisartan have a strong recommendation as first‑line preventive agents【@2】【@4】.
CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab) also receive a strong recommendation for episodic migraine prevention【@2】【@4】.
Beta‑blocker propranolol carries a weak‑for recommendation as a preventive option【@2】【@4】.
Topiramate is given a weak‑for recommendation for episodic migraine prevention【@1】【@2】【@4】.

Do not use botulinum toxin for typical vestibular migraine with episodic attacks, as this aligns with the episodic migraine pattern where Botox is ineffective and may be harmful【@1】【@2】.
Do not confuse chronic migraine with frequent vestibular migraine attacks; chronic migraine requires ≥ 15 headache days per month, not merely frequent vertigo episodes【@1】.