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original
SUPLEMENTO
Otoneurología 2014:
comprendiendomejor los trastornos vestibulares
Actual.Med.
2014; 99: (791). Supl. 38-60
VMasa single treatment.
Lomerizine,anothercalciumantagonist,hasshownresolution
or significant improvement of the symptoms in a retrospective
study inpatientswithmigraine-associatedvertigo (40).
Otherspreventivedrugs
Acetazolamide is a carbonic anhydrase inhibitor diuretic. In
the inner ear it would act by inhibiting carbonic anhydrase in the
stria vascularis and supporting cells of the sensory epithelia. The
efficacyof acetazolamide for theprophylaxis ofmigraine is judged
unknownbytheAAN-AHAguidelines.Nevertheless,acetazolamide
hasbeenused successfully inpatientswith familial vestibulopathy,
familial migraine with vertigo and tremor, episodic ataxia type 2,
hemigplegicmigraine, CADASILmigraine and episodic ataxiawith
migrainous features without headache (41,42,43). Acetazolamide
hasbeenused inVMpatientsbutno studiesareavailable.
NSAIDS such as ibuprofen, ketoprofen and naproxen are
consideredprobably effective formigraine prevention (level B) by
theAAN/AHS (44),butwedidnotfindanyclinical studyconcerning
VM. Ciproheptadine and flurbiprofen are possibly effective for
preventive treatment of migraine headache; ciproheptadine is
useful forprophylaxisof childhoodbenignparoxysmal vertigo.
Some triptans are effective for the short-term prevention of
menstrual migraine, but there is no available evidence in other
prophylactic indications includingVM.
VESTIBULARREHABILITATION
Somestudiesandcase reportshavesuggested thatvestibular
rehabilitation might be an effective treatment for VM patients.
Vestibular rehabilitation could improve motion sensitivity, visual
dependence,confidencewiththeirbalance,andpostural instability.
Whitney et al. (2000), in a retrospective case series of
patients with migraine-related vestibulopathy, observed a
significant improvement in theDizzinessHandicap Inventory (DHI),
the Activities-Specific Balance Confidence Scale (ABC), and the
DynamicGait Index (DGI), and a disability composite score after
a custom-designed physical therapy exercise program. Falls also
decreased. Interestingly, patients who received antimigraine
drugs compared with the nonmedicated patients improved
significantlymore in theoutcomemeasures (45).
In a second study of the same group, Wrisley et al. also
performed a retrospective case series study in patients with
vestibular disorders with and without history of migraine.
Authors appreciated significant differences in theDHI, DGI, ABC,
PerceptionofDizzinessSymptoms (PDS) scale, and theTimedUp
& Go test after vestibular physical therapy within both groups.
Interestingly, patients with a history of migraine improved less
in outcomemeasures than did the patientswithout a history of
migraine (46).
Posteriorly, Gottshall et al. investigated the effects of a
customizedvestibular rehabilitationprogramused inconjunction
withpreventivemigraine treatment for patients presentingwith
migraine-associated dizziness. DHI, ABC and DGI significantly
improved after physical therapy, as well as the sensory
organization test scoreoncomputerizeddynamicposturography.
However, medicated to nonmedicated individuals were not
compared (47).
Very recently, Vitkovic et al. have undergone a prospective
study to assess the efficacy of vestibular rehabilitation in VM
patients compared to a nonmigrainous vestibular dysfunction
group (48). The authors have proven the effectiveness of a nine
week vestibular rehabilitation program using a wide variety of
outcome measures, both subjective and physical performance.
UnlikeWhitney´s study, the same degree of improvement was
appreciated regardless ofmedicationuse.
It is striking that neither of the above mentioned studies
has evaluated the frequencyof vertigoepisodes.
Futureperspectives
New drugs are being developed to treat migraine attacks:
5-HT
1F
receptoragonists, SPantagonists, CGRPantagonists, nitric
oxide synthetase inhibitors and ion channel antagonists. For
preventivetreatmenthumanmonoclonalantibodiestoCGRPand
its receptor arealsounder investigation (49). It is tobeexpected
that someof these targed-baseddrugsmaybeeffective inVM.
TREATMENTSTRATEGY
Patient involvement
The first step inmanaging VM is patient acceptance of the
diagnosis. For this, it isessential informingabout thenatureofhis
symptoms.Youneedtoexplaintoyourpatienttherelationvertigo-
migraine, especiallywhen general physician andmany specialists
are skeptic and reluctant to recognize this clinical entity. It is also
necessarytoenquirepatient’sconcernsand identifyhisexpectations
toclarifyanyaspect related to thedisorderand its therapy.
It is appropriated to discuss with the patient therapeutic
options and their potential adverse events. The patient has to
express his preferences and we encourage him to participate
actively inmakingdecisions that affect his life. Thefinal goal is to
create an individualizedplan to treat andprevent VM symptoms.
Thisapproachmaximizes treatment compliance.
The engagement of the patients in their own heath may
be accomplished in the preparation of aMV diary for registering
the episodes (table 3). This is a useful tool for confirming the
suspected diagnosis, for trigger identification, and evaluating the
effectivenessof a therapy.
Table3.General Principles.
Drug choice
Acute treatment
The choice of suitable drug depends on themain symptom
(nausea-vomiting or vertigo), and the expected side effects.
Acutemedicationalsoneeds tobe tailored toattackdurationand
severity. For mild nausea we prescribe dimenhydrinate whereas
for vomiting we prefer thiethylperazine; metoclopramide is
reserved for severe vomiting. For vertigo we use sulpiride. A
benzodiazepinemaybegivenat bedtimedoses.
For mild symptoms these drugs are given orally. When the
patient cannot tolerate this route, suppositories or intramuscular
injectionareuseful inoutpatient setting. For severeattacks in the
emergency department or for inpatient setting parenteral route
ispreferred.
In any case, we recommendutilizing theminimum effective
dosage of the drug; do not make use of vestibular suppressant
more than three days while avoiding the combination of drugs
withantidopaminergiceffects.
• Involvepatients in their own care
• RecommendaVMdiary
• Consider pharmacological and non-pharmacological
preventive therapy
• Choose a preventive drug based on the efficacy in
migraine
• Dealwith sideeffects and coexisting conditions
• Start with the lowest dose and titrate upward
gradually
• Re-evaluated therapyafter a2-3month trial
