39
Otoneurología 2014:
comprendiendomejor los trastornos vestibulares
SUPLEMENTO
original
Actual.Med.
2014; 99: (791). Supl. 39-60
Preventive treatment
Both pharmacological and non-pharmacological therapy
shouldbeconsidered.
Choice of a preventive drug for a specific patient must be
individualized and based on the efficacy, the side effect profile,
coexistingconditions,patientpreferencesandphysicianexperience.
TheuseofanydruginVMisnotwellsupportedbyrandomized,
placebo-controlled clinical trials. Most available studies are
observational and/or retrospective analyses, with small sample
size; moreover they use different diagnosis criteria. Therefore,
there is insufficient clinical evidence to evaluate the impact on
qualityof life,andtheeffectivenessofpreventivepharmacotherapy
in reducing the frequency, intensity and duration of VM attacks.
Large randomized placebo-controlled double-blind clinical trials
are needed, with sufficient follow-up and uniform criteria. The
generalizedacceptanceof thediagnostic criteriadevelopedby the
Bárány Society and IHSwill undoubtedly contribute to clarify this
issuewhileallows comparing the results of different studies. In this
regard, theCochraneLibraryhaselaboratedaprotocol toassess the
effectsofpharmacological treatments forthepreventionofVM (50).
We recommend as first line drugs for VM beta-blockers
(propranolol,metoprolol), topiramate,amitriptylineandflunarizine.
Data derived frommigraine headache studies recognize that these
drugs combine high quality evidence with a positive balance
betweenbenefitsandundesirableeffects.Wedonotusevalproate
forVMas it isnot approved formigraine inSpain.
At equivalent doses, there is no significant difference
in efficacy among propranolol, amitryptiline, topiramate and
flunarizine. Today there is not sufficient evidence to establish
the superiority of one option over another. Thus, choice among
preventive medications relies mainly on differences in adverse
effects and possible comorbid diseases (table 4). Nevertheless, in
some patientsmay be advisable to treat two co-existing diseases
independently. Forexample, ifhypertension iswell controlledwith
furosemide there is noneed to introduce abeta-blocker and then
amitriptylinecouldbeabetteroption.
Table4.Drug selection forVM.
It is important to discuss with the patient the need of a
prophylactic treatment, toexplain thealternativesand todevelopan
individualizedplantotreatandpreventhisorhersymptoms.Weconsider
crucial that patients understand why amitriptyline or propranolol is
prescribedwhentheydonotsufferfromdepressionorhypertension.
We recommend that the practitioner familiarizes himself
with theuseofonedrugof eachpharmacological group.
Scheduling
Therapy shouldbe initiatedwith the lowest doseof thedrug
andtitrateupward gradually until reachminimum effective dose as
determinedby apositivebenefit/risk ratio. If thepatient reports no
benefitafter threemonthsat theoptimal doseweconsider thedrug
as being ineffective in that particular patient. A preventive drug is
regardedaseffectivewhenat leasta50% reduction in the frequency
ofVMepisodes isachievedwithin3months.Thenanothermedication
belonging toanotherpharmacologicalgrouphas tobe tried.
Monotherapy is preferred but in refractory patients when
various drugs have failed a combination of drug from different
groupsmaybe tried.Amitriptylineplusbeta-blockerorflunarizine;
or topiramate plus beta-blocker are appropriate combination but
beta-blockerplusflunarizine shouldbeavoided.
After6to9monthsofeffectivetreatment,westoppreventive
therapy by tapering slowly the dose. The natural history of VM is
unknown but it appears to improve over time with no need of
specific treatment. Tapering down is advisable because it avoids
amitriptyline discontinuation symptoms (severe nausea, strong
headache, insomnia), the potential risk of seizures, even in non-
epileptic subjects, with topiramate withdrawal, and rebound
hypertensionafterbeta-blockerabrupt cessation.
A stepwiseapproach isproposed infigure1.
Figure1.
Drugof choice
discouraged
Asthma
Beta-blockers
Bipolar disorder
Valproate,
topiramate
Depression
amitriptyline
topiramate,
flunarizine
Diabetesmellitus
Beta-blockers
Epilepsy
Valproate,
topiramate
amitriptyline
Essential tremor
Beta-blockers
Hypertension
Beta-blockers,
flunarizine
Valproate,
topiramate
Hypotension,
arrhythmias
Valproate,
topiramate
Beta-blockers,
amitriptyline,
flunarizine
Insomnia
amitriptyline
Obesity
Topiramate
Flunarizine,
amitriptyline,
valproate
Tensionheadache amitriptyline
Severe
impact on
quality of
life
Counselling
Dietary changes
Lifestylemodifications
Counselling
Dietary changes
Lifestylemodifications
Drug therapy
Frequency
<50%
Tolerable
sideeffects
3mo.
NO
NO
YES
Frequency
<50%
NO
Tryanother
pharmacological group
or consider increase
dosage
3mo.
NO
Tryanother
pharmacological group
orCombine twodrugsof
different pharmacological
group
YES
3mo.
Keep3 mo.Re-evaluate
and then consider
tapering.
YES
3mo.
YES
YES
NO
Refer tootoneurologist
Frequency
<50%
Tolerable
sideeffects
Frequency
<50%
Tolerable
sideeffects
