Key messages
It is not clear whether any of these treatments are effective at preventing attacks of vestibular migraine.
Few studies have assessed the possible benefits and harms of using these treatments to prevent attacks.
The studies found are small and the results are inconclusive.
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 or 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. Sometimes people may also try non-drug treatments to help prevent or improve their symptoms and try to reduce how often attacks occur. This might include changing their diet (such as eating less salt) or taking supplements (such as vitamins or minerals). Other treatments range from talking therapies to physiotherapy.
What did we want to find out?
We wanted to find out:
- whether there was evidence that any non-drug treatments 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 types of treatment to either no treatment or placebo (dummy) treatment. We used standard methods to assess the quality 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 319 people (84% were female). These studies looked at three different types of treatments, to assess whether they might help to prevent vestibular migraine attacks, or help to reduce the symptoms when episodes occur.
Probiotics
The first study looked at the use of probiotics - these are a type of bacteria that can be taken as a supplement to the normal diet. It was unclear whether this treatment made any difference to vertigo symptoms in people with vestibular migraine, or changed the frequency of attacks. The study did not report any information on possible harms, so we do not know if there are any risks associated with taking this treatment.
Cognitive behavioural therapy (CBT)
CBT is a type of talking therapy, which aims to help improve problems by changing the way people think and behave. One small study assessed whether CBT helps to prevent attacks of vestibular migraine. However, it was not clear whether this treatment had an effect on people's symptoms or the frequency of vertigo attacks. Again, no information was reported on possible harms of the treatment.
Vestibular rehabilitation
Vestibular rehabilitation is a form of physiotherapy that includes specific exercises to try and improve problems with balance. Another small study compared vestibular rehabilitation to no treatment in people with vestibular migraine. Again, the results were inconclusive and we cannot be sure whether this treatment has any effect on changing people's symptoms, or the frequency of attacks. No information was reported on potential harms of the treatment.
What are the limitations of the evidence?
We have very little confidence in the evidence included in this review. The three studies conducted were small and there were some problems with their conduct, which means that the results may be unreliable. Overall, it was not clear whether any of the treatments assessed were of benefit in the treatment of vestibular migraine. Importantly, none of the studies reported any information about harms, so we cannot tell if there are any possible risks associated with these treatments.
How up-to-date is this evidence?
This evidence is up-to-date to September 2022.
There is a paucity of evidence for non-pharmacological interventions that may be used for prophylaxis of vestibular migraine. Only a limited number of interventions have been assessed by comparing them to no intervention or a placebo treatment, and the evidence from these studies is all of low or very low certainty. We are therefore unsure whether any of these interventions may be effective at reducing the symptoms of vestibular migraine and we are also unsure whether they have the potential to cause harm.
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 interventions have been used, or proposed to be used, as prophylaxis for this condition, to help reduce the frequency of the attacks. Many of these interventions include dietary, lifestyle or behavioural changes, rather than medication.
To assess the benefits and harms of non-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 dietary modifications, sleep improvement techniques, vitamin and mineral supplements, herbal supplements, talking therapies, mind-body interventions or vestibular rehabilitation 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 in this review with a total of 319 participants. Each study addressed a different comparison and these are outlined below. We did not identify any evidence for the remaining comparisons of interest in this review.
Dietary interventions (probiotics) versus placebo
We identified one study with 218 participants (85% female). The use of a probiotic supplement was compared to a placebo and participants were followed up for two years. Some data were reported on the change in vertigo frequency and severity over the duration of the study. However, there were no data regarding improvement of vertigo or serious adverse events.
Cognitive behavioural therapy (CBT) versus no intervention
One study compared CBT to no treatment in 61 participants (72% female). Participants were followed up for eight weeks. Data were reported on the change in vertigo over the course of the study, but no information was reported on the proportion of people whose vertigo improved, or on the occurrence of serious adverse events.
Vestibular rehabilitation versus no intervention
The third study compared the use of vestibular rehabilitation to no treatment in a group of 40 participants (90% female) and participants were followed up for six months. Again, this study reported some data on change in the frequency of vertigo during the study, but no information on the proportion of participants who experienced an improvement in vertigo or the number who experienced serious adverse events.
We are unable to draw meaningful conclusions from the numerical results of these studies, as the data for each comparison of interest come from single, small studies and the certainty of the evidence was low or very low.