Key messages
It is not clear whether any medications are effective at preventing attacks of vestibular migraine.
There are very few studies that have assessed the possible benefits and harms of taking medication to prevent attacks. The available studies are small and the results are inconclusive.
Further work is needed in this area to help establish whether there are any treatments that may improve this condition.
What is vestibular migraine?
Migraine (sometimes known as 'headache migraine') is a common condition that causes recurrent headaches. Vestibular migraine is a related condition where the main symptoms are recurring episodes of severe dizziness or vertigo (a spinning sensation). These episodes are often associated with headache, or other migraine-like symptoms (such as sensitivity to light or sound, nausea and vomiting). It is a relatively common condition, which affects up to 1 in every 100 people, and can have severe effects on day-to-day life.
How is vestibular migraine treated?
Typical treatment plans include medications to try and stop an attack of vertigo once it has started, or to improve the symptoms. In addition, people may use treatments intended to prevent attacks from starting (prophylactic or preventative treatment). There are no widely recommended treatments to prevent or manage the symptoms of a vestibular migraine attack. People are sometimes advised to take medications used to treat headache migraine. The assumption is that these medicines may also work for vestibular migraine.
What did we want to find out?
We wanted to find out:
- whether there is evidence that any medications work to prevent attacks of vestibular migraine, or reduce the symptoms when an attack occurs;
- whether the treatments might cause any harm.
What did we do?
We searched for studies including adults that compared different medications to either no treatment or placebo (dummy) treatment. We used standard methods to assess the certainty of the evidence. We rated our confidence in the evidence, based on factors such as study methods, the number of participants in them and the consistency of findings across studies.
What did we find?
We found three studies, which included a total of 209 people (65% female). These studies looked at two different types of medicines, to assess whether they might help to prevent vestibular migraine attacks, or help to reduce the symptoms when episodes occur.
Beta-blockers
The first study looked at the use of a medicine called metoprolol, a tablet taken once daily. Metoprolol is from a group of medications known as beta-blockers. These are often used to treat high blood pressure, but are also used to try and prevent attacks of headache migraine. It was unclear whether this treatment made any difference to the frequency of vertigo attacks, or whether it was associated with any serious harms.
Calcium channel blockers
Two smaller studies assessed the use of flunarizine, a tablet taken once a day. This is from the family of medications known as calcium channel blockers. Again, these medicines are commonly used to control high blood pressure, but are also used for headache migraine. It was very unclear whether people felt their symptoms had improved when taking this treatment and whether the frequency of their vertigo attacks changed. The studies did not report on serious harms of the treatment, so we do not know if there were any risks associated with taking the medication.
What are the limitations of the evidence?
We have very little confidence in the evidence because the three studies conducted were small. There were also some problems with the conduct of the studies, which means that the results may be unreliable. These medications are often used for other conditions, where they are known to be associated with some side effects. However, we did not identify enough information in this review to know whether these side effects are a problem when the treatments are used for vestibular migraine.
How up-to-date is this evidence?
This evidence is up-to-date to September 2022.
There is very limited evidence from placebo-controlled randomised trials regarding the efficacy and potential harms of pharmacological interventions for prophylaxis of vestibular migraine. We only identified evidence for two of our interventions of interest (beta-blockers and calcium channel blockers) and all evidence was of low or very low certainty. Further research is necessary to identify whether these treatments are effective at improving symptoms and whether there are any harms associated with their use.
Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used or proposed to be used as prophylaxis for this condition, to help reduce the frequency of the attacks. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar.
To assess the benefits and harms of pharmacological treatments used for prophylaxis of vestibular migraine.
The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.
We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing beta-blockers, calcium channel blockers, antiepileptics, antidepressants, diuretics, monoclonal antibodies against calcitonin gene-related peptide (or its receptor), botulinum toxin or hormonal modification with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.
We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.
We included three studies with a total of 209 participants. One evaluated beta-blockers and the other two evaluated calcium channel blockers. We did not identify any evidence for the remaining interventions of interest.
Beta-blockers versus placebo
One study (including 130 participants, 61% female) evaluated the use of 95 mg metoprolol once daily for six months, compared to placebo. The proportion of people who reported improvement in vertigo was not assessed in this study. Some data were reported on the frequency of vertigo attacks at six months and the occurrence of serious adverse effects. However, this is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results.
Calcium channel blockers versus no treatment
Two studies, which included a total of 79 participants (72% female), assessed the use of 10 mg flunarizine once daily for three months, compared to no intervention. All of the evidence for this comparison was of very low certainty. Most of our outcomes were only reported by a single study, therefore we were unable to conduct any meta-analysis. Some data were reported on improvement in vertigo and change in vertigo, but no information was available regarding serious adverse events. We are unable to draw meaningful conclusions from the numerical results, as these data come from single, small studies and the certainty of the evidence was very low.