Vestibular Migraine describes migraine which has symptoms that are located in the vestibular system which includes the inner ear and balance system. As always, all information below MUST be discussed with your doctor.

Symptoms

· VM symptoms can be extremely debilitating for many patients. According to the ICDH Vestibular Migraine must include at least five vestibular symptoms which must last b/w 5 mins and 72 hours, and half of all attacks must include a migraine symptom (head pain, light sensitivity, sound sensitivity, or aura). Vestibular Symptoms include dizziness, vertigo, lightheadedness, depersonalization, brain fog, ataxia, photophobia, anxiety and tinnitus, among others.

· Typical migraine symptoms are also involved in VM but headache is not always present. Infact, almost 50% of patients experience VM without headache.

· Differential diagnosis by a neurologist is useful to determine whether symptoms are VM or if they could be Ménière’s Disease, or BPPV (Benign paroxysmal positional vertigo).

Treatment

Lifestyle modifications:

· Standard Migraine Lifestyle modifications (SEEDS) are even more important with VM. Sleep, Eating, VM Exercises, keeping a migraine Diary, and Stress Management can be used to mitigate VM symptoms.

· Limiting or stopping caffeine can be helpful (caffeine can increase tinnitus symptoms).

· Consider dietary changes such as the low-tyramine diet or Heal Your Headache diet (HYH).

Preventive medications:

· Beta-Blockers (Propranolol and Metapronol)
· Calcium Channel Blockers (Verapamil and Flunarazine)
· SNRIs (especially Venlafaxine/Effexor)
· Nortriptyline
· Topamax
· Lamotrigine (esp. for vertigo)
· Timolol eye drops
· Anti-CGRPs

Acute Medications:

· Triptans (specifically Zolmitriptan and Rizatriptan)
· Diazepam for episodes lasting 2 to 3 hours
· Lorazepam or Clonazepam for longer attacks
· Timolol Eye Drops
· Betahistine (Serc)

Nutritional Supplements:

· Vitamin B2
· CoEnzyme Q10
· Magnesium (Glycinate and Threonate are best for VM. Threonate can help with some of the brain fog issues)

Neuromodulation devices for VM:

Some studies show that non-invasive vagus nerve stimulation (nVNS) like Gammacore and the trigeminal nerve stimulation device Cefaly, can be helpful.

VRT (Vestibular Rehabilitation Therapy):

VRT is “an exercise-based treatment program designed to promote vestibular adaptation and substitution. The goals of VRT are: to enhance gaze stability, to enhance postural stability, to improve vertigo and to improve activities of daily living.” (Journal of Clinical Neurology). If you do not know of any physiotherapists or other healthcare professionals specializing in VRT, this link has listings for Canadian cities.

Resources:

· VEDA Vestibular Disorders Association

· The Dizzy Cook

References:

1. https://americanmigrainefoundation.org/resource-library/vestibular-migraine/

2. https://www.migraineagain.com/vestibular-migraine-treatments/

3. https://thedizzycook.com/vestibular-migraine-symptom-dictionary-an-interview-with-dr-

   cho-from-house-clinic/

4. https://americanheadachesociety.org/wp-content/uploads/2018/05/

   Migraine_Associated_Vertigo_November-December_2015.pdf

5. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3259492/

6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3105632/

7. https://americanheadachesociety.org/wp-content/uploads/2020/09/AHS-Fact-Sheet_Vestibular-Migraine.pdf