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Review Article
Preventive medical treatment of vestibular migraine: a practical review
Jae-Hwan Choi1orcid, Kwang-Dong Choi2orcid, Eun Hye Oh1orcid, Seo-Young Choi2orcid
Research in Vestibular Science 2025;24(1):20-26.
DOI: https://doi.org/10.21790/rvs.2024.024
Published online: March 14, 2025

1Department of Neurology and Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea

2Department of Neurology and Biomedical Research Institute, Pusan National University Hospital, Pusan National University School of Medicine, Busan, Korea

Corresponding author: Seo-Young Choi Department of Neurology, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea. E-mail: csy035.12@gmail.com
• Received: November 23, 2024   • Accepted: December 27, 2024

© 2025 The Korean Balance Society

This is an open access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • This review explores the medical treatment options for vestibular migraine (VM), focusing on preventive strategies and their evidence-based efficacy. VM, characterized by recurrent dizziness associated with migraine, requires tailored management due to its distinct clinical features and pathophysiology. Most VM treatments are derived from migraine management protocols, utilizing medications such as BBs, CCBs, and antiepileptic drugs. Meta-analyses revealed that flunarizine, propranolol, and venlafaxine significantly reduced vertigo frequency and Dizziness Handicap Inventory scores, although the evidence was limited by small sample sizes and methodological inconsistencies. Flunarizine showed benefits in reducing vertiginous episodes but was less effective for headache. Venlafaxine demonstrated additional improvements in depressive symptoms. Observational studies also indicated potential efficacy for propranolol and valproate. Emerging therapies, such as calcitonin gene-related peptide monoclonal antibodies, showed promise in improving both vestibular and headache symptoms in small-scale trials, though further evidence is needed to establish their role in VM management. The selection of preventive medications for VM should be individualized, considering both the frequency and severity of vestibular and headache symptoms, as well as patient comorbidities and preferences. While existing migraine protocols offer some guidance, the need for VM-specific treatment strategies remains critical.
  • Keywords: Migraine; Disease prevention; Vertigo; Headache
The co-occurrence of vertigo or dizziness with headaches has been a common area of research since the early 1900s [1]. While results vary across epidemiological studies, it is estimated that 10% to 40% of patients with headache experience dizziness or vertigo as an accompanying symptom [1,2]. Because these symptoms often overlap, with no clear temporal relationship, and both rely on subjective patient reports for diagnosis, terms such as ‘migrainous vertigo’ and ‘migraine-associated vertigo’ had been used interchangeably. Recently, diagnostic criteria for vestibular migraine (VM) have been established collaboratively by the International Classification of Headache Disorders [3] and the Bárány Society (Table 1) [4].
VM is more prevalent in women and influenced by both environmental and genetic factors like migraine [2,5]. Also, VM may share pathophysiological mechanisms of cortical spreading depression with migraine [6]. This is a phenomenon in migraines that activates the trigeminal nociceptive system [7] contributed to sensory hypersensitivity [8], which is directly linked between the trigeminal nucleus caudalis and vestibular nuclei, and the presence of calcitonin gene-related peptide (CGRP)-expressing neurons in the vestibular nuclei [9]. However, VM tends to present with distinctive characteristics, including longer headache duration, higher intensity of headaches, and increased incidences of motion sickness and depression [5,10], which may require a specific treatment strategy distinct from that of migraine.
Currently, there are no definitive guidelines for VM treatment. Based on its presumed shared pathophysiology with migraines [2,11], treatment strategies often include the use of migraine medications alongside rehabilitation and lifestyle modifications [5,12]. Evidence on preventive medications remains limited, with few randomized studies specifically targeting VM. Recent meta-analyses [13] and systematic reviews have noted significant heterogeneity and a lack of standardized reporting, making it challenging to draw firm conclusions on optimal preventive strategies [2,13]. This review aims to focus on a more practical, experience-based discussion of the medical treatment of VM, drawing on recent research findings.
The Korean Headache Society Guideline for Preventive Medical Treatment of Migraine [14]
Although current migraine treatment guidelines do not specifically address the control of vestibular symptoms, VM is treated based on migraine protocols. Preventive medication guidelines for migraine with or without aura have been published in various countries [14-16]. In 2021, the Korean Headache Society issued guidelines for the preventive treatment of migraines, recommending various indications and medications for preventive therapy [14]. The recommended medications for migraine include antihypertensive and antiepileptic drugs, antidepressants, and CGRP monoclonal antibodies (mAbs).
Preventive treatment for migraines is recommended in cases where symptoms significantly impact daily life, where there is a lack of response to acute treatment, or where, despite effective acute treatment, headaches occur frequently—especially if acute treatment is required more than 10 to 15 times per month [15]. Preventive treatment may also be considered regardless of headache frequency if preferred by the patient or deemed necessary based on the physician’s clinical judgment [15].
Meta-Analysis of Preventive Medications for Vestibular Migraine
Currently, clinical management of VM often follows migraine treatment guidelines, utilizing beta-blockers (BBs), calcium channel blockers (CCBs), antiepileptic drugs, antidepressants, and anti-CGRP antibodies [1]. Migraine prevention medications are typically recommended based on their efficacy in reducing headache intensity and frequency [15]. However, in VM, medication selection should also account for the frequency and severity of dizziness and its impact on quality of life, warranting a more tailored approach [5]. Further research is essential to establish a clear, evidence-based rationale for VM-specific treatment strategies [1,9].
A recent meta-analysis including studies on 13 medications, such as lamotrigine, paroxetine, amitriptyline, flunarizine, venlafaxine, valproate, nortriptyline, propranolol, and cinnarizine, showed that all treatment options analyzed resulted in improvements across outcome parameters. However, due to significant heterogeneity and lack of standardized outcome reporting, a preferred treatment modality could not be established [13].
A 2023 Cochrane Review analyzed prophylactic treatments for VM but found only very limited evidence from placebo-controlled trials, ultimately including three studies [17]. In an RCT in 2019, comparing the BB of metoprolol to placebo, there was a reduction in mean monthly vertigo frequency and improvements in Dizziness Handicap Inventory (DHI) scores; however, these changes did not reach statistical significance compared to placebo [18]. The review included two studies on the effects of the CCB of flunarizine, one of which showed significant reductions in the frequency and severity of vertiginous episodes, although no significant effects were found on headache frequency or intensity [19]. Notably, this study did not report baseline data and analyzed grouped multiple scale points, making the findings less clear [19]. Another open-label RCT compared flunarizine and betahistine to a betahistine-only group, finding significant reductions in the frequency, intensity, and duration of vertiginous episodes, though no clear analysis was performed on headache outcomes [20].
In a study analyzing seven RCTs through network meta-analysis, valproate, propranolol, and venlafaxine were found to significantly reduce the frequency of VM episodes compared to placebo/control groups, although only one study included valproate or propranolol, and two studies included venlafaxine [21].
Research and Clinical Applications on Preventive Medication for Vestibular Migraine
Propranolol is a BB of effective preventive medication for controlling headache in migraine patients [22]. Although no randomized study has compared propranolol with placebo for VM, a study involving 38 patients who received propranolol at various doses over 6 to 32 months demonstrated significant improvements in DHI scores and the activities of daily living scores [23]. In an open-label prospective randomized trial with 64 participants, propranolol and venlafaxine were each administered for 4 months, showing significant DHI improvements of around 25 to 31 points for both drugs, as well as a reduction in vertigo attacks by approximately 10 episodes per month [24]. While no difference was observed in the efficacy of the two drugs on vertigo frequency, venlafaxine significantly improved depressive symptoms. This study did not assess headache outcomes [24]. Propranolol effectively reduces the frequency of VM attacks [21] and demonstrates good adherence, making it a recommended option for treatment. However, it is not recommended as a primary choice for patients with asthma, type 1 diabetes mellitus, bradycardia, or hypotension [1].
The primary CCB used in migraine management are flunarizine and cinnarizine, while verapamil, previously studied for migraine, is now more commonly used for cluster headache [1]. CCBs are frequently discussed for their potential utility in VM, not only due to their role in managing headache of migraine but also because they are often tried as treatment options for peripheral vestibular vertigo [25].
In the Cochrane Review mentioned earlier, a study involving 52 VM patients who were administered 10 mg/day of flunarizine for 12 weeks showed that while there was no significant reduction in headache, flunarizine significantly decreased the frequency and severity of vertiginous episodes [19]. In a randomized trial comparing flunarizine 10 mg daily, venlafaxine 37.5 mg daily, and sodium valproate 500 mg twice daily, the flunarizine group did not show superior efficacy over the other two medications. However, a before-after comparison within the flunarizine group demonstrated significant reductions in vertigo severity, frequency, and DHI scores [26].
Cinnarizine and lomerizine may also be effective in VM, though the evidence supporting these is less substantial than for flunarizine [9]. Reported side effects include dry mouth, blurred vision, somnolence, and weight gain, but these are generally mild, and discontinuation due to these effects is uncommon [1].
Valproate and topiramate are established preventive medications for migraine and are strongly recommended in the clinical guidelines of the Korean Headache Society [14,15]. The study demonstrating the efficacy of valproate in VM is the randomized trial comparing flunarizine, venlafaxine, and valproate. Administration of valproate at 500 mg twice daily for 3 months significantly reduced vertigo frequency and DHI scores in a before–after comparison. However, it did not show a significant reduction in vertigo severity compared to the other two medications [26]. In a randomized trial involving 30 patients with migrainous vertigo, topiramate at doses of 50 mg/day and 100 mg/day was found to significantly reduce vertigo frequency, vertigo severity, and headache severity [27]. There was no dose-dependent effect observed, rather, the rate of medication discontinuation due to side effects was significantly higher in the 100 mg/day group [27]. Also particular caution is required when prescribing valproate to women of childbearing age due to its teratogenic effects [14]. Similarly, topiramate also warrants caution in this population and is contraindicated in patients with a history of kidney stones [1,14].
Antidepressants have long been used as treatments for migraines, based on their mechanism of inhibiting the reuptake of serotonin and noradrenaline, which plays a role in pain modulation [28]. In the Korean Headache Society's migraine treatment guidelines, tricyclic antidepressants are recommended strongly, while venlafaxine and nortriptyline are classified as “can be recommended” [14]. Similarly, the American Headache Society categorizes both amitriptyline and venlafaxine as “probably effective” [15]. Fluoxetine, the selective serotonin reuptake inhibitor (SSRI), is not included in the both of Korean and American guidelines for migraine [14], and the American Headache Society guidelines do not include SSRIs. Instead, they include serotonin-norepinephrine reuptake inhibitors such as venlafaxine and duloxetine [15].
Research on VM patients remains limited, with only a few small-scale studies available. In a multicenter prospective observational study involving acetazolamide, amitriptyline, flunarizine, propranolol, or topiramate, 24 patients used amitriptyline for 5 weeks, resulting in significant reductions in vestibular symptoms and headache intensity. However, side effects such as somnolence were reported, and only 16 of the 24 patients were included in the final analysis [29]. In a randomized study of 64 VM patients comparing venlafaxine to propranolol over 4 months, venlafaxine demonstrated an equivalent effect to propranolol in reducing the frequency and severity of vertigo [24].
In a randomized study evaluating venlafaxine, valproate, and flunarizine over a 3-month treatment period, the venlafaxine group (23 patients) showed significant reductions in DHI scores, vertigo severity, and vertigo frequency in a before-and-after comparison. Furthermore, venlafaxine demonstrated superior efficacy in the emotional domain of the DHI compared to the other two medications [26].
The Emergence of New Therapies: Calcitonin Gene-related Peptide Monoclonal Antibodies
The recent introduction of CGRP-targeting medications for migraine prevention has marked a transformative era in migraine therapy. CGRP has been shown to play a role in the vasodilation of the trigeminovascular system associated with migraines, with its receptors distributed in pain-inducing pathways within the hypothalamus and brainstem, as well as in the terminals of peripheral nerves [30,31]. Subsequent studies confirmed elevated blood levels of CGRP during migraine attacks in migraine patients [31]. Such clear evidence collectively led to the development of small-molecule CGRP receptor antagonists and mAbs targeting either CGRP itself or its receptor for migraine [30]. It is known that CGRP receptors are distributed in the brainstem, particularly in the vestibular nuclei, which share a similar pathophysiology with migraine. This suggests that CGRP medications may not only alleviate headaches but also improve vestibular symptoms [8,32].
New CGRP-related medications are in preparation for approval, but currently, there are now four approved for use in the United States for migraine: eptinezumab, erenumab, fremanezumab, and galcanezumab. Eptinezumab, fremanezumab, and galcanezumab target the CGRP ligand, and erenumab targets the CGRP receptor. Erenumab, fremanezumab, and galcanezumab are administered as subcutaneous injections, and eptinezumab is the first migraine preventive administered as an intravenous infusion [15]. In South Korea, subcutaneous injectable CGRP mAbs, fremanezumab and galcanezumab, are currently available for clinical use for migraine. While their efficacy has been demonstrated, their high cost compared to oral medications has prompted the American Headache Society to establish criteria to help medical professionals balance cost-effectiveness with access to care [15]. They recommend prescribing these treatments in cases where more than 8 weeks of proven-effective medications fail to provide sufficient benefits or cause intolerable side effects [15]. Additionally, the low long-term adherence rates associated with oral preventives suggest that CGRP mAbs, administered as injections once a month or every 3 months, may improve patient preference and compliance [15].
In a recent RCT on galcanezumab for definite and probable VM, 17 patients with medication showed a significantly greater reduction in DHI scores compared to the placebo group (n=21) (8.3 vs. 22.0 points, p=0.018). Additionally, the number of dizziness days per month decreased from 18 to 12.5 days in the placebo group and from 17.9 to 6.6 days in the galcanezumab group, representing a difference of –5.7 days (p=0.026) after 4 months of treatment. No serious adverse effects were reported [33]. This study is the only RCT to date evaluating a CGRP-blocking medication for VM, and it demonstrated a clear effect of CGRP mAbs in VM. However, the study had a small sample size due to its unexpected early termination when the sponsor ceased medication supply at a single center.
A prospective observational study involving 50 VM patients treated with erenumab, fremanezumab, or galcanezumab over 18 months demonstrated promising results. In this study, 45 patients (90%) achieved at least a 50% reduction in vertigo frequency, 43 (86%) had at least a 50% reduction in headache frequency, and 40 (80%) showed a 50% or greater reduction in Migraine Disability Assessment Scale scores. Additionally, the mean monthly days with dizziness or vestibular symptoms decreased dramatically, from 10.3 days at baseline to 0.8 days at 12 months, indicating excellent efficacy [32]. In a retrospective study involving 25 patients treated with various types of CGRP medications over different durations, 15 patients experienced moderate or greater improvement in global symptoms, including headache and dizziness [34].
The choice of preventive medication for VM should be individualized, considering each patient’s specific characteristics and the potential side effects of each drug. Recently, although medications prescribed based on migraine criteria can be clinically effective and their efficacy has been somewhat validated, there remains a need to establish treatments specifically tailored for VM.

Funding/Support

This study was supported by the Biomedical Research Institute Grant (No. 202400720001) of Pusan National University Hospital.

Conflicts of Interest

Jae-Hwan Choi and Kwang-Dong Choi are the Editorial Board members of Research in Vestibular Science and were not involved in the review process of this article. The authors declare no other conflicts of interest.

Availability of Data and Materials

The datasets are not publicly available but are available from the corresponding author upon reasonable request.

Authors’ Contributions

Conceptualization, Methodology, Investigation, Funding acquisition: Choi SY; Data curation: All authors; Formal analysis: Oh EH; Writing–original draft: Choi JH, Choi KD; Writing–review and editing: Choi SY.

All authors read and approved the final manuscript.

Table 1.
Diagnostic criteria for vestibular migraine
Criterion Detail
A At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
B Current or past history of migraine with or without aura, as defined by the ICHD-3
C One or more migraine features with at least 50% of vestibular episodes:
- Headache with at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, or worsening with routine physical activity
- Photophobia and phonophobia
- Visual aura
D Not better accounted for by another vestibular or ICHD diagnosis

ICHD, International Classification of Headache Disorders.

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        Preventive medical treatment of vestibular migraine: a practical review
        Res Vestib Sci. 2025;24(1):20-26.   Published online March 14, 2025
        DOI: https://doi.org/10.21790/rvs.2024.024
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      Preventive medical treatment of vestibular migraine: a practical review
      Preventive medical treatment of vestibular migraine: a practical review
      Criterion Detail
      A At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
      B Current or past history of migraine with or without aura, as defined by the ICHD-3
      C One or more migraine features with at least 50% of vestibular episodes:
      - Headache with at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, or worsening with routine physical activity
      - Photophobia and phonophobia
      - Visual aura
      D Not better accounted for by another vestibular or ICHD diagnosis
      Table 1. Diagnostic criteria for vestibular migraine

      ICHD, International Classification of Headache Disorders.

      Table 1.

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