Acute Treatments for Vestibular Migraine

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. This seems to be one of the most prescribed triptans for people with vestibular migraine.

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, especially if people also have pain with attacks, as mentioned in our interview.

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.

Two acute treatments you may not know – hydroxyzine and cyproheptadine. These can provide relief from pain as well as potentially help anxiety symptoms.

Cyproheptadine is a histamine and serotonin antagonist and has been successfully used at preventing migraine in children. It is also used for pediatric vertigo.

Because antihistamines are sedating and can help lower anxiety, some physicians like to use them instead of benzodiazepines as they don’t have the same level of risk of addiction.

However, antihistamines for vestibular migraine 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 side effect is they can be sedating and cause weight gain.

My personal experience with hydroxyzine and cyproheptadine were that they helped with mild attacks and I slept very well, but the next day I was groggy and extremely hungry. After a few days of taking hydroxyzine, I found I would consume a lot more food than usual. I find they are a good alternative for my rare, mild attacks. For me, they did not replace the effectiveness of ativan.

Benzodiazepines for Vertigo

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 vertigo 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. 

For me, Ativan for vertigo attacks was extremely effective and still is to this day. These days I just take as needed for dizziness, but when I was ready to wean off migraine medication, I had no issue at the low dose I was taking. You can review my treatment plan with all the details.

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.

Menstrual Migraine Options

If you’re someone who has an increase in symptoms around your period, this may be helpful.

Vitamin E proved to be effective for menstrual migraine in reducing the frequency and severity of attacks. 400IU daily for 5 days is recommending, beginning 2-3 days before your cycle through the beginning of it.

Acetazolamide (Diamox) is generally prescribed for altitude sickness, but has been studied in the prevention of vestibular migraine. Out of 50 patients, the majority experienced relief from vertigo and headache frequency, with a big emphasis on it being most effective for vertigo.

For menstrual migraine, 500mg daily, starting 2-3 days before the predicted menstrual cycle for 5 total days resulted in a significant improvement. The biggest relief was reported with symptoms of nausea, dizziness, pain, and light and sound sensitivity.

A previous study had showed acetazolamide may not be well tolerated for daily treatment, and it seems to work better as an acute treatment. Potential uses could be for menstrual migraine, air travel or high altitude travel. I also wonder if it could be helpful for barometric pressure induced attacks.

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 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, this could be helpful for anxiety, stress, and nausea.

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.

gammaCore for Vestibular Migraine

This nVNS device is also known as gammaCore and can be used at home. It is available as both a preventative and acute treatment. It used to cost $600 a month, but the pricing has been reduced to make it more affordable. If your doctor is a part of a hospital research program, the cost is $150 a month for 3 months of treatment, or you can get a similar discount with my code.

I’ve always wanted to try this device and it worked out to test it during my postpartum phase when I was struggling with more vestibular migraine attacks due to lack of sleep. I found it to not only be helpful to reduce dizziness, nausea, and head pain (something new for me after IVF and pregnancy with migraine), but also to help bring down my anxiety. The best part was that I could use it as an acute treatment without it compromising my mental clarity or driving ability, like many medications do.

Each stimulation is 2 minutes and feels like a gentle buzz. Each session is usually 2 stimulations on the same side for a total of 4 minutes. With gammaCore you rent the device for 3 months at a time.

I share my journey with using gammaCore as a migraine treatment, so don’t miss out if you’re interested. Use my code dizzycook for 15% off your gammaCore device.

Truvaga

Truvaga is another nVNS, vagus nerve stimulation, device that is not approved for the treatment of migraine like gammaCore. However, it can help with some of the health issues we need help with like better sleep, less stress, and clearer thinking. The devices are very similar in how they work.

With Truvaga, you can buy the 350, which has 350 preloaded sessions on it, or the unlimited. I’ve used both and love that I can use the unlimited whenever I need to, as well as everyday, but dislike that it has to be connected to my phone. Use my code AFFILIATE10 for a discount.

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. Typically this stimulation is beneficial for those with any kind of head pain or sinus pressure.

Cefaly 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 (for preventative and acute treatment) for a discount if you only want to use it for one or the other. Once purchased, you own the device.

Sessions are comprised with 20 and 60 minute sessions, but since the device is placed on your forehead, it can be tricky to move around. I like to use this while meditating or laying down for a break.

Cefaly has recently been studied for vestibular migraine attacks, but I initially felt it provoked my dizziness. With their new Cece app, you can better control the intensity of the stimulations. I prefer to keep mine on a lower setting, and it helps immensely with any pain or head pressure days.

I find Cefaly to be the most effective for pain and head pressure out of all the devices, so I highly recommend it, especially if you have one sided pain. They give you a 60 day trial period to see if you like it. Get 15% off Cefaly with code dizzycook.

Nurtec for Vestibular Migraine

I have not personally tried any of the new gepants for vestibular migraine, but they are becoming popular because they do not have the risk of rebound like triptans. These work by inhibiting CGRP, which is responsible for head pain signaling in the brain. Generally relief is felt within 2 hours.

Nurtec (rimegepant) is a tablet that has been approved for both the acute treatment and preventative treatment of migraine. Studies have shown it’s been helpful for light sensitivity, sound sensitivity and nausea, which can be common with vestibular migraine attacks. There’s really no information on Nurtec for vertigo specifically.

While I’ve heard mixed reviews from vestibular migraine friends, just like any of these treatments it’s worth a try! Although Ubrelvy and Reyvow fall into the same category, Nurtec seems to be the most popularly prescribed for vestibular migraine specifically.

Vestibular Migraine Treatment at Home

Some acute vestibular migraine treatments at home that 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. 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. I started viewing it as another migraine treatment instead of a luxury, especially since it’s just as helpful as some of my medications.

Overall, I believe we know what works best for us, it’s just sometimes doing it that’s the difficult part. I hope this post gives you some great ideas to discuss with your physician regarding acute vestibular migraine and vertigo treatments.