Treatment of vestibular migraine currently lacks a firm scientific basis, as high quality randomized controlled trials are not available. Therefore, recommendations are largely borrowed from the migraine sphere. The first therapeutic step is explanation and reassurance. Many patients do not need pharmacological treatment, as attacks may be infrequent and tolerable. Acute attacks can be ameliorated in some patients with antiemetic drugs such as diphenhydramine, meclizine, and metoclopramide. Frequent attacks may warrant pharmacological prophylaxis with metoprolol, amitriptyline, topiramate, valproic acid, or flunarizine. Nonpharmacological measures including regular exercise, relaxation techniques, stress management, and biofeedback may be similarly effective and can be combined with a pharmacological approach. Limited data indicate that the prognosis appears to be less favorable for vestibular migraine than for migraine headaches.
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