What is the role of prophylactic medications in the treatment of migraine-associated vertigo?

Updated: Jun 17, 2021
  • Author: Aaron G Benson, MD; Chief Editor: Arlen D Meyers, MD, MBA  more...
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Prophylactic medical therapy should be used when migraine-associated vertigo occurs several times a month, is continuous over several weeks or months, or has severely affected the patient's lifestyle. First-line prophylactic medications include calcium channel blockers (verapamil), tricyclic antidepressants (nortriptyline), and beta blockers (propranolol). Second-line treatments include topiramate, valproic acid, venlafaxine, and methysergide. Acetazolamide and lamotrigine have also been reported as an effective treatment by several authors. However, these 2 medications seem to be primarily effective for only the vestibular symptoms and not headaches. [36]

The actual mechanism of action for migraine control with these medications is unknown. However, the calcium channel blockers, tricyclic antidepressants, beta blockers, and methysergide are believed to block the release of neuropeptides into dural blood vessel walls, because of their antagonist effect on serotonin (5-HT)-2 receptors.

One class of prophylactic medication does not seem to be more effective than the others. Therefore, unless contraindicated, verapamil is often used initially, because this medication has the lowest side-effect profile among the prophylactic medications.

If dizziness is not controlled with one class of medication, another class should be used. If dizziness is controlled with one of these medications, the drug should be administered continuously for at least 1 year (except for methysergide, which requires a 3- to 4-week drug-free interval at 6mo). The medication can be restarted for another year if the dizziness returns after discontinuing therapy.

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