Vestibular Migraine Treatment Guidelines

Acute Attack Treatment

Alternative triptans include rizatriptan 10 mg, naratriptan 2.5 mg, or zolmitriptan 2.5-5 mg if sumatriptan is ineffective or poorly tolerated, according to Praxis Medical Insights 1
Treat early in the attack when symptoms are still mild to maximize efficacy, as delayed treatment reduces response rates, as noted in Nature Reviews Neurology 2, 3
Consider antiemetics such as metoclopramide 10 mg or prochlorperazine 10 mg for nausea, which also provide synergistic analgesia, as recommended by Nature Reviews Neurology and Praxis Medical Insights 1, 3
NSAIDs (ibuprofen, naproxen sodium, or diclofenac potassium) can be used for mild-to-moderate attacks or combined with triptans to prevent symptom relapse, according to Nature Reviews Neurology 2, 3
Limit acute medication use to no more than 2 days per week to prevent medication-overuse headache, which affects both the headache and vestibular components, as advised by Praxis Medical Insights 1, 4

Initiate preventive therapy when attacks occur more than twice weekly, cause significant disability, or when acute medication use becomes excessive, as recommended by Nature Reviews Neurology and Praxis Medical Insights 1, 2
Valproic acid may be used but is absolutely contraindicated in women of childbearing potential, as noted in Nature Reviews Neurology 5

Relaxation training, thermal biofeedback combined with relaxation, and cognitive-behavioral therapy are effective adjuncts that can be combined with preventive drug therapy, as recommended by Praxis Medical Insights 1

Avoid confusing vestibular migraine with Menière's disease; the key differentiator is the absence of hearing loss in vestibular migraine, and do not allow patients to increase acute medication frequency in response to persistent symptoms, as this creates medication-overuse headache; instead, escalate to preventive therapy, as advised by Praxis Medical Insights 4

Preventive therapy requires 2-3 months for oral agents to demonstrate full efficacy, so counsel patients about this timeline to maintain adherence, as recommended by Praxis Medical Insights 4