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. 2023 Apr 12;4(4):CD015322.
doi: 10.1002/14651858.CD015322.pub2.

Pharmacological interventions for acute attacks of vestibular migraine

Katie E Webster  1 , Afrose Dor  2 , Kevin Galbraith  1 , Luma Haj Kassem  3 , Natasha A Harrington-Benton  4 , Owen Judd  5 , Diego Kaski  6 , Otto R Maarsingh  7 , Samuel MacKeith  8 , Jaydip Ray  9 , Vincent A Van Vugt  7 , Martin J Burton  10
Affiliations

Pharmacological interventions for acute attacks of vestibular migraine

Katie E Webster et al. Cochrane Database Syst Rev. .

Abstract

Background: 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. OBJECTIVES: To assess the benefits and harms of pharmacological interventions used to relieve acute attacks of vestibular migraine.

Search methods: 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Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials.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.

Selection criteria: 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. DATA COLLECTION AND ANALYSIS: 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. MAIN RESULTS: 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). AUTHORS' CONCLUSIONS: 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.

Trial registration: ClinicalTrials.gov NCT00360282.

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Conflict of interest statement

Katie Webster: none known.

Afrose Dor: none known.

Luma Haj Kassem: none known.

Kevin Galbraith: none known.

Natasha A Harrington‐Benton: Natasha Harrington‐Benton is the Director of the Ménière's Society, a national charity supporting people with vestibular conditions. The Ménière’s Society supports research in various ways, including distributing surveys and/or providing grant funding for projects studying vestibular conditions. Some of the studies they have previously funded may be included in the review. They do not carry out the research themselves and are not directly involved in projects.

Owen Judd: none known.

Diego Kaski: none known.

Otto R Maarsingh: none known.

Samuel MacKeith: Samuel MacKeith is the Assistant Co‐ordinating Editor of Cochrane ENT, but had no role in the editorial process for this review. He sees patients with vestibular migraine disease in his NHS and private practice and is the co‐director of a company providing private vestibular function testing services.

Jaydip Ray: none known.

Vincent A Van Vugt: none known.

Martin J Burton: Martin Burton undertook private practice until March 2020 and saw some patients with balance disorders, including vestibular migraine. He is the Co‐ordinating Editor of Cochrane ENT, but had no role in the editorial process for this review.

Figures

1
1
Flow chart of study retrieval and selection.
2
2
The Cochrane Pregnancy and Childbirth Trustworthiness Screening Tool
3
3
Risk of bias graph (our judgements about each risk of bias item presented as percentages across all included studies).
4
4
Risk of bias summary (our judgements about each risk of bias item for each included study).
1.1
1.1. Analysis
Comparison 1: Triptans versus placebo, Outcome 1: Improvement in vertigo (global score)
1.2
1.2. Analysis
Comparison 1: Triptans versus placebo, Outcome 2: Improvement in headache
1.3
1.3. Analysis
Comparison 1: Triptans versus placebo, Outcome 3: Improvement in other migrainous symptoms
1.4
1.4. Analysis
Comparison 1: Triptans versus placebo, Outcome 4: Other adverse effects
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References

References to studies included in this review

NCT02447991 {published data only}
    1. NCT02447991. Rizatriptan for episodic dizziness in vestibular migraine [A phase II/III trial on rizatriptan for vestibular migraine]. http://clinicaltrials.gov/show/NCT02447991 (first received 19 May 2015). [CLINICALTRIALS.GOV: NCT02447991]
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ACTRN12616000683437 {published data only}
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Furman 2009 {published data only}
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Furman 2011 {published data only}
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    1. NCT00360282. Does a migraine medication decrease rotational motion sickness in people suffering from migraines? [Effect of rizatriptan on rotational motion sickness in migraineurs]. https://clinicaltrials.gov/show/nct00360282 (first received August 2006). [CENTRAL: CN-00856751]
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