Management
Treatment & prevention
The evidence base is modest and largely borrowed from migraine, so management is pragmatic: a behavioural foundation for everyone, symptom relief for attacks, and preventives reserved for frequent or disabling disease.
What the evidence supports
Most people improve a lot by keeping a steady routine — regular sleep, meals and hydration, and cutting back on personal triggers. Tablets are added when attacks are frequent or disabling, and are chosen to suit the individual.
Randomised evidence specific to VM is limited; a Cochrane review found insufficient high-quality trial data to recommend any one preventive agent definitively, and practice is largely extrapolated from migraine.1 A systematic review and meta-analysis nonetheless supports benefit from preventive pharmacotherapy and lifestyle measures in practice.2
Set expectations accordingly: aim for fewer, milder attacks rather than cure, choose preventives by comorbidity and tolerability, and give each an adequate trial (typically 8–12 weeks at target dose) before judging it. Avoid chronic vestibular suppressants, which blunt central compensation.
The treatment ladder
Three tiers: a behavioural foundation for everyone, acute relief during attacks, and preventive pharmacotherapy for frequent or disabling disease.
Foundation — for everyone
- Trigger & lifestyle managementRegular sleep, meals, hydration; reduce caffeine/alcohol; manage stress.
- Headache & vertigo diaryIdentify personal triggers and track attack frequency to gauge response.
- Vestibular rehabilitationFor interictal imbalance and visually-induced dizziness.
Acute attack — symptom relief
- TriptansMay help in some; evidence is limited and best for those with prominent headache.
- Short-course antiemetics / vestibular suppressantsFor relief in a severe attack — short-term only, not daily.
- Rest in a quiet, dark roomReduce sensory load; most attacks are self-limiting.
Prevention — frequent or disabling attacks
- Beta-blocker (propranolol, metoprolol)A common first-choice preventive; avoid in asthma/bradycardia.
- Amitriptyline / nortriptylineUseful where sleep or comorbid headache/anxiety coexist.
- TopiramateEffective for migraine; watch cognitive effects, weight loss, paraesthesiae.
- Flunarizine / cinnarizineCalcium-channel blockers with trial support in VM where available.
Reserve preventives for frequent or disabling attacks; avoid chronic vestibular suppressants, which blunt central compensation. Choose by comorbidity and tolerability.
Choosing a preventive
There is no single first-line agent; match the drug to the patient. A beta-blocker (propranolol, metoprolol) suits the anxious or hypertensive without asthma; amitriptyline or nortriptyline suits coexisting insomnia or tension-type headache; topiramate suits those who would welcome weight loss and can tolerate its cognitive effects; flunarizine or cinnarizine are useful where available.2 Where migraine is prominent and refractory, CGRP-targeted therapies used for migraine are an emerging option.
Rehabilitation and the bigger picture
For interictal imbalance, visual dependence or secondary vestibular rehabilitationcan help recondition the central response. Manage comorbid anxiety and sleep, and review the diagnosis if the pattern drifts — VM’s criteria themselves invite re-evaluation over time.3
Key points
- Trigger and lifestyle management is the foundation for every patient.
- Reserve preventives (beta-blocker, amitriptyline, topiramate, flunarizine) for frequent or disabling attacks.
- Give each preventive an adequate trial; choose by comorbidity and tolerability.
- Avoid chronic vestibular suppressants; use vestibular rehabilitation for interictal symptoms.