Acute Treatments for Vestibular Migraine

Vestibular migraine can produce daily dizziness, but also can occur with episodic, disabling attacks. This fluctuation in symptoms can be stabilized by using preventative medications, which work to prevent attacks before they happen. But as people living with migraine know, occasionally some attacks slip through and we’re left scrambling to get rid of them as quickly as they came on. This is where acute migraine treatments come in.

When used either at the first sign of symptoms or in the midst of a full blown attack, these vestibular migraine treatments can either help to completely stop the symptoms or lessen the severity of the attack. For typical migraine attacks that involve head pain, these are usually analgesics like naproxen (Aleve), ibuprofen, acetaminophen, triptans (migraine specific pain meds), and ergotamines.

Vestibular Migraine Attack Symptoms

Very little has been studied on the effect of these with vestibular migraine. Those who live with VM know that not every attack involves a headache or head pain. In fact, up to 50% of people can have vestibular migraine attacks without any headache present. So what kind of symptoms are experienced during a bad vestibular migraine attack?

These can include (but are not limited to):

• Vertigo, which is usually defined as a spinning sensation in clinics, where either you feel as though you are spinning, or the world around you is.
• Continuous dizziness that feels like a foggy brain or lightheadedness, like you’re about to pass out.
• Drop attacks – feeling as though you are falling
• False sense of movement – not limited to drop attacks or vertigo, this can be moving from side to side, intense rocking, or like you’re floating
• Alice in Wonderland Syndrome – where objects or body parts appear smaller or larger than what they are.
• Visual distortions and visual snow
• Derealization and depersonalization – a disconnect the environment around you or from your body

If none of these sensations cause pain, but are just are terrifying and debilitating in their own way, how do we stop them? Here are a few new and existing vestibular migraine treatments that can be used acutely. 

Triptans for Vestibular Migraine

Up until recently, I truly believed the only effective acute medications for vestibular migraine that existed were benzodiazepines and antihistamines like meclizine. It was previously thought that triptans were ineffective against vertigo, and only worked for migraines with head pain. However, some small studies show a little bit of success. Two randomized trials showed a little bit of evidence supporting the use of rizatriptan and zolmitriptan for vestibular migraine attacks.

In one of the studies rizatriptan showed some promise in 15 subjects who experienced motion sickness due to vestibular issues. 13 of the 15 showed a decrease in motion sickness after taking the rizatriptan, compared to the placebo. However, with an increase in stimulation, the patients did not receive a continued benefit.

In another small study, zolmitriptan showed some benefit in a dosage of 5mg, proving useful in 3 out of 8 vestibular migraine attacks. However, the placebo group showed benefit in 2 out of 9 attacks.

Again, both these studies are limited because of the amount of participants, but when looking at Vestibular Migraine as a whole, there are really only a few small studies to go off in general. This type of treatment is something Dr. Beh is tending to prescribe more, as mentioned in our interview back in March.

Antihistamines for Migraine

Medically these are referred to as meclizine, dimenhydrinate, and diphenhydramine. You may know these are Antivert, Dramamine, and Benadryl because as mixed antihistamine/anticholinergics they are commonly the go-to for doctors to prescribe when patients mention vertigo episodes. These are vestibular suppressants, not meant to be used for prevention, but can be used acutely and are found over-the-counter making them easy to access without a prescription.

These are always kind of glazed over when talking about vestibular migraine, especially in studies. It seems because they are widely known and tend to help with motion sickness, they’re often recommended. However, they may not be the most effective treatment you can find. I personally see these as an easy place to start, but don’t be discouraged if you don’t see a huge benefit for stopping a severe vestibular migraine attack. The other commonly reported drawback is they can be sedating.

Benzodiazepines

Benzos like Ativan (Lorazepam), Valium (Diazepam), and Klonopin (Clonazepam) can be used in the lowest dosages for acute treatment vestibular migraine attacks. In my interview with Dr. Beh, we discussed how these aren’t always the first protocol for attacks, but they can be effective for people who aren’t helped by other methods like antihistamines or non-pharmacological treatments. Dr. Beh mentioned these tend to be useful for patients who also experience increased anxiety with their attacks. Dr. Timothy Hain shares a stepped protocol where he begins with Meclizine before transitioning into certain benzodiazepines. He states certain benzos tend to be less sedating but have an increase in dependency. Some are not prescribed due to their high risk of dependency, such as Xanax (alprazolam). 

As discussed in this post on managing migrainous vertigo attacks, the use for these can be controversial due to addiction. This is something Dr. Hain has visited previously on his site, in which he says the risk can be decreased by staying with the lowest possible doses and taking as prescribed. Compensation should not be a concern on these low doses. 

Timolol Eye Drops

Something I talk about often as it was part of my own vestibular migraine treatments, is Timolol Eye Drops. Most commonly used for glaucoma patients, these eye drops are basically a lower dosage of beta blockers, which have shown success for migraine prevention.

The interesting twist is that because these can be administered through the eyes or as a nasal spray, the medication is absorbed much faster into the blood stream than taking an actual pill.

Again, a small study showed success with using these as an acute treatment for migraine with head pain. I cannot say for sure if this is just something that I tested in Dr. Beh’s clinic, or if this is a more widely used treatment for vestibular migraine, but it does work for me and quite a few vestibular migraine friends. No studies have shown the success with this medication and vestibular migraine specifically.

Neuromodulation Devices for Vestibular Migraine

One exciting and recent study, published by Dr. Shin Beh and Dr. Deborah Friedman, reviewed the benefits of nVNS (which stands for noninvasive vagus nerve stimulation) as an acute treatment for vestibular migraine.

Your vagus nerve (which is pronounced “Vegas nerve” although I sometimes have a really difficult time saying that when it just sounds like a nerve that likes to party), basically connects your gut to your brain. So naturally it makes sense that with a type of migraine that can affect our gut so much, a stimulation device for it makes sense.

The study tested 18 patients, 14 with a VM attack, and found that vertigo was reduced in 13 or the 14 patients. 4 patients with PPPD were also tested and found no improvement.

This nVNS device is also known as Gammacore and can be used at home, however it is quite expensive. The approximate cost is roughly $600 a month. Perhaps ask your neurologist to test it out in the office to see if you find a benefit. As we all know, the price of these treatments directly coordinates with how desperate we are for relief. If it gives you relief, it’s worth its weight in gold!

Cefaly for Vestibular Migraine

Another neuromodulation device that’s being used within my clinic is the Cefaly. This device stimulates the trigeminal nerve instead of the vagus nerve, so it’s placed on the forehead rather than the neck. Cefaly Dual comes with two settings, an acute and preventative setting. The total cost is $499, and then you purchase the electrodes which have about 10-20 uses. You can also purchase the devices  separately (a preventative and acute) for a large discount of $100 right now.

While this device hasn’t exclusively been tested for vestibular migraine, my neurologist has recommended it to me as a drug-free option for my vestibular migraine attacks. I’ll admit that I have resisted trying it because of the price. Should I have an increase in attacks in the future, I’d be more willing to try it out. They do give you a 60 day trial period to see if you like it. 

Natural Relief for Dizziness

Some acute vestibular migraine treatments that are natural and you may already have on hand include:

• Extra Magnesium
• Magnesium Baths, Lotion, or Foot Soaks
• Cognitive Behavioral Therapy, Tapping, or Visualization
• Motion Sickness Bands
• Increase Hydration
• Decreasing Stress 

I know the last one is really difficult – everyone tells us to do this, but it is easier said than done. This really should be its own separate post for a later date. But truly this can look different for every individual. For me, I had to make a really tough decision to leave my old job as all my other stress relief tactics weren’t enough. You know it’s probably an issue when your neurologist, nurse practitioner, family, husband, and therapist are all telling you to quit your job.

I also added in massage therapy every two weeks as a scheduled appointment. Financially, it’s expensive, but my mental health (and neck) benefitted a ton from this investment. Overall, I believe we know what works best for us, it’s just sometimes doing it that’s the difficult part.