Key messages
It is not clear whether any medications are effective at treating attacks of vestibular migraine.
There are few studies that have assessed the possible benefits and harms of taking medication at the time of an attack. 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 be used to help relieve the symptoms of a vestibular migraine attack.
What is vestibular migraine?
Migraine (sometimes known as 'classical 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?
Key approaches to treatment include trying to prevent attacks from starting (preventative treatment), as well as treatments to relieve the symptoms of an attack. There are no widely recommended treatments to manage the symptoms of a vestibular migraine attack. People are sometimes advised to take medicines 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 was evidence that any medications work to relieve or stop attacks of vestibular migraine;
- whether the treatments might cause any harm.
What did we do?
We searched for studies in adults that compared different medications 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 two studies, which included a total of 133 people (75% female). Both studies looked at a specific type of medication known as triptans. The evidence showed that taking a triptan may make very little difference to the number of people whose vertigo symptoms improved. However, there are problems with the evidence, which means that we are uncertain about this result.
One of the studies looked at side effects related to this medication and found that nobody developed serious side effects. However, as this study only included 114 people, it was too small to assess this properly. Therefore, we are not sure whether there may be a risk of harms from taking these treatments.
What are the limitations of the evidence?
We have very little confidence in the evidence because the studies conducted were small. There were also some problems with the conduct of the studies, which means that the results may be unreliable. We know that triptans may cause some side effects in people who use them for headache migraine, but we were not able to find out if these side effects are also common when the medications are used for vestibular migraine.
How up-to-date is this evidence?
This evidence is up-to-date to September 2022.
The evidence for interventions used to treat acute attacks of vestibular migraine is very sparse. We identified only two studies, both of which assessed the use of triptans. We rated all the evidence as very low-certainty, meaning that we have little confidence in the effect estimates and cannot be sure if triptans have any effect on the symptoms of vestibular migraine. Although we identified sparse information on potential harms of treatment in this review, the use of triptans for other conditions (such as headache migraine) is known to be associated with some adverse effects.
We did not identify any placebo-controlled randomised trials for other interventions that may be used for this condition. Further research is needed to identify whether any interventions help to improve the symptoms of vestibular migraine attacks and to determine if there are side effects 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. The 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, at the time of a vestibular migraine attack to help reduce the severity or resolve the symptoms. 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 interventions used to relieve acute attacks 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 triptans, ergot alkaloids, dopamine antagonists, antihistamines, 5-HT3 receptor antagonists, gepants (CGRP receptor antagonists), magnesium, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) with either placebo or no treatment.
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: < 2 hours, 2 to 12 hours, > 12 to 72 hours. We used GRADE to assess the certainty of evidence for each outcome.
We included two RCTs with a total of 133 participants, both of which compared the use of triptans to placebo for an acute attack of vestibular migraine. One study was a parallel-group RCT (of 114 participants, 75% female). This compared the use of 10 mg rizatriptan to placebo. The second study was a smaller, cross-over RCT (of 19 participants, 70% female). This compared the use of 2.5 mg zolmitriptan to placebo.
Triptans may result in little or no difference in the proportion of people whose vertigo improves at up to two hours after taking the medication. However, the evidence was very uncertain (risk ratio 0.84, 95% confidence interval 0.66 to 1.07; 2 studies; based on 262 attacks of vestibular migraine treated in 124 participants; very low-certainty evidence). We did not identify any evidence on the change in vertigo using a continuous scale. Only one of the studies assessed serious adverse events. No events were noted in either group, but as the sample size was small we cannot be sure if there are risks associated with taking triptans for this condition (0/75 receiving triptans, 0/39 receiving placebo; 1 study; 114 participants; very low-certainty evidence).