When patients with migraine associated vertigo present with clear features of BPPV or Meniere's disease, they should be treated with standard treatment for those disorders (particle repositioning maneuver for BPPV, diuretics, salt restriction and possible surgical intervention for Meniere's disease). Meniere's attacks associated with prominent headache can also be treated with calcium channel blockers.
The management of acute spells depends largely on the duration and severity. Severe spells that last longer than 20 minutes can be treated pharmacologically. If the patient is able to swallow a pill, then oral meclizine, promethazine or prochloperazine can be used. We prefer promethazine for its efficacy and because it can be substituted 1:1 in the suppository form, which can be used if nausea from the vertigo is severe. All antiemetics are potentially sedating so patients should be adequately warned not to drive after taking these medications. Many patients find that a good nap or good night's sleep will break a vertigo attack and welcome the sedating effects. Benzodiazepines are also effective vestibular suppressants but have the potential for tolerance and dependency and should be used with caution.
As is the true for all episodic disorders, the mainstay of preventative treatment is to avoid triggers. Many patients report triggers for vertigo that are very similar to triggers for typical migraine headaches. These include stress, lack of sleep, dietary fluctuations, fluctuations in caffeine intake, certain kinds of foods, weather changes and menstrual cycles. Controlled trials of medications for idiopathic recurrent vertigo are lacking but anecdotal reports of the efficacy of acetazolamide have lead to the more widespread use of this medication. We find it helpful for patients who have clear attacks of rotatory vertigo. The rationale for trying acetazolamide, a carbonic anhydrase inhibitor was based on the efficacy of this drug in reducing recurrent vertigo in patients with EA2.47
The action of acetazolamide in the brain that renders its efficacy is still unknown, but P31
MRS have shown that treatment lowers the pH of the extracellular space in patients with episodic ataxia.48
An acidic extracellular environment leads to decreased neuronal excitability, whereas an alkaline environment is associated with increased excitability. The main side effects of acetazolamide include paresthesias, dehydration, lethargy and sometimes myalgias. Acetazolamide can also decrease potassium levels. In general, we start this medication at a low dose (125 mg a day) and only increase it by 125 mg a week to a goal dose of 250 mg twice daily. We encourage patients to drink generous amounts of citrus juices to avoid the alkalinization of urine, which leads to the formation of kidney stones.
We also use verapamil in the extended release form, which works well for patients with recurrent vertigo and migraine headaches. A small case series of patients with recurrent vertigo and chronic headaches showed efficacy with typical anti-migraine medications including pizotifen, a calcium channel blocker, verapamil and propranolol.49
The longer acting form is associated with fewer drops in blood pressure and we are able to use this medication frequently in young women who generally have low blood pressure.
Selective serotonin reuptake inhibiting medications can be effective and are generally most useful in patients who have concurrent mood disorders. Chronic dizziness of any kind, particularly with unpredictable spells, are extremely anxiety provoking and can lead to a complex interaction of otogenic and psychogenic factors that can lead to prolonged disability.50
The use of SSRIs can help address the vertigo attacks as well as the adjustment reaction to the attacks.