Introduction
Vestibular migraine (VM) is a prevalent yet underdiagnosed condition characterized by recurrent vertigo episodes associated with migraine symptoms, such as headache, phonophobia, and photophobia. Affecting an estimated 1–2.7% of the population (Mallampalli et al., 2022),
VM represents the intersection of neurological and vestibular disorders. Pathophysiologically, VM involves disruptions in the trigemino-vascular system (TVS), nociceptive brainstem centers, and vestibular nuclei (Hannigan et al., 2024).
Central sensitization, neuroinflammation, and abnormal thalamocortical network activity exacerbate these symptoms, with calcitonin gene-related peptide (CGRP) playing a pivotal role in the disorder’s manifestation (Zhang et al., 2020).
Despite advancements in diagnostic criteria, the lack of a universal biomarker complicates the clinical differentiation of VM from conditions like benign paroxysmal positional vertigo (BPPV) and Meniere’s disease. Collaborative efforts in refining diagnostic algorithms, such as those proposed by Mallampalli et al. (2022), are essential for reducing the diagnostic delay, which averages 8.4 years.
Non-Pharmacological Treatments
Nutritional Supplements
The role of mitochondrial-targeted supplements, including magnesium, riboflavin, and coenzyme Q10, has been substantiated in multiple studies. Hannigan et al. (2024) observed that 44% of VM patients achieved symptom reduction using these supplements. Such interventions are minimally invasive and hold promise as first-line therapies, particularly in mild cases. Gaul et al. (2015) corroborated these findings, emphasizing their safety profile and potential for improving mitochondrial function in VM management.
Lifestyle Modifications
Lifestyle changes, encompassing sleep optimization, hydration, stress reduction, and targeted exercise routines, synergize with nutritional therapy to enhance symptom control. Mallampalli et al. (2022) advocated for incorporating vestibular rehabilitation exercises, tailored to mitigate maladaptive vestibular hypersensitivity, as part of a holistic management plan.
Pharmacological Treatments
Beta-Blockers and Calcium Channel Blockers
Pharmacological agents such as propranolol and flunarizine provide partial relief for VM symptoms by modulating neural hyperactivity. However, their sedative and weight-gain side effects limit their long-term viability (Smyth et al., 2022). Beta-blockers, often prescribed as second-line options, are recommended for patients unresponsive to nonprescription therapies (Hannigan et al., 2024).
CGRP Monoclonal Antibodies
Emerging therapies, such as CGRP antagonists, offer a targeted approach by addressing neuroinflammatory pathways. Zhang et al. (2020) demonstrated their efficacy in reducing vestibular hypersensitivity and associated vertigo episodes. Preliminary trials, including those reviewed by Mallampalli et al. (2022), underscore their potential, though long-term studies are needed to validate their effectiveness in VM.
Comparative Analysis
Non-pharmacological approaches, while effective in mild-to-moderate cases, lack the rapid symptom control afforded by pharmacological interventions. Hannigan et al. (2024) highlighted the lower side effect burden of supplements and lifestyle changes, making them preferable for long-term management. Conversely, pharmacological treatments remain critical for refractory cases where symptom severity demands immediate relief.
Care Gaps and Recommendations
Mallampalli et al. (2022) identified significant gaps in VM management, including the need for refined diagnostic criteria, enhanced provider education, and robust outcome measures. A global registry and standardized diagnostic tools, incorporating perceptual threshold testing and biomarkers like CGRP levels, could bridge these gaps.
Conclusion and Future Directions
An integrated treatment paradigm combining non-pharmacological strategies with pharmacological interventions offers the most comprehensive approach to VM management. Continued research into the underlying pathophysiology, including the role of CGRP and thalamocortical networks, is crucial for developing targeted therapies. Collaborative efforts among neurologists, audiologists, and physiotherapists will further optimize outcomes for VM patients.
References
• Gaul, C., Diener, H. C., & Danesch, U. (2015). Improvement of migraine symptoms with a proprietary supplement containing riboflavin, magnesium, and Q10: A randomized, placebo-controlled trial. Journal of Headache and Pain, 16(1), 32.
• Hannigan, I. P., Rosengren, S. M., Di Tanna, G., Watson, S. R. D., & Welgampola, M. S. (2024). Effects of nonprescription therapies on vestibular migraine: A questionnaire-based observational study. Internal Medicine Journal, 54, 916–924.
• Mallampalli, M. P., et al. (2022). Care gaps and recommendations in vestibular migraine: An expert panel summit. Frontiers in Neurology, 12, Article 812678.
• Smyth, D., Britton, Z., Murdin, L., Arshad, Q., & Kaski, D. (2022). Vestibular migraine treatment: A comprehensive practical review. Brain, 145(11), 3741–3754.
• Zhang, Y., et al. (2020). Calcitonin gene-related peptide facilitates sensitization of the vestibular nucleus in a rat model of chronic migraine. Journal of Headache and Pain, 21(72).