A Personal Spin on Migraine-Associated Vertigo Treatments: With few formal guidelines, otolaryngologists use trial and error

Lifestyle and Diet

Therapy usually means first exploring non-pharmacological approaches. “Really you go back to the migraine treatment: You try to address lifestyle changes, avoiding stress, getting a good night’s sleep, trying to avoid too much caffeine or any trigger,” said Maroun Semaan, MD, associate director of the otology, neurotology and balance disorders section at University Hospitals of Case Medical Center in Cleveland, Ohio. Yoga and psychotherapy sometimes help, he added.

“Migrainers are hypersensitive to all sensory stimuli and that includes side effects of medications,” Dr. Foster said. “So you end up with a group [for whom] there are medicines we can use to help, but they won’t take them. So I usually start with a non-medicine approach, and then only if that fails do I go on to using a migraine prophylactic.”

Several otolaryngologists said patients can help themselves by taking vitamin supplements, notably riboflavin and magnesium, the latter of which may reduce a type of vasospasm thought to be linked to migraines. Dr. Foster said she reviews several pages full of possible triggers with patients. Cheese, yogurt and monosodium glutamate often play big roles. Other otolaryngologists cite eggs, wine and nicotine.

Regulating sleep cycles may also do wonders. Dr. Foster said she now regularly questions her migraine patients about sleep apnea, after noticing an unusually strong connection between the two. Similarly, she estimated that about 25 percent of her Ménière’s disease patients have sleep apnea. “It turns out that sleep apnea presents as an early morning headache, often, in a patient who snores,” she said. “And in people who have any kind of migraine tendency, it presents as a severe exacerbation of migraine, which can include the vertigo part.”

If those patients can tolerate wearing a CPAP (continuous positive airway pressure) device at night, she has discovered, their symptoms often resolve.

Modifying a patient’s diet may be especially important for children or pregnant women who cannot take many of the available medications. Among children with migraines, Dr. Goebel has gained the upper hand over previously out-of-control symptoms by limiting patients’ intake of caffeine and sugar, especially by curtailing caffeinated sodas that might produce wild swings in sugar levels. He experienced similar success by advising patients to limit their intake of cheese on pizza and other foods.

“The problem with Inderal as a beta blocker is that if you give it to a younger person, not only does it lower their blood pressure, but it lowers their exercise tolerance.”

—Joel Goebel, MD

Medication

When medication becomes necessary, otolaryngologists often have their favorite standbys as first-line treatments. Experts, however, said several considerations are warranted regardless of the regimen. Dr. Foster said she tailors prophylactic medications to the severity and full suite of a patient’s symptoms, as well as the side-effect profiles of candidate drugs. Dr. Semaan recommended starting the medication slowly and increasing the amount based on the patient’s tolerance, then staying with the medication for at least six months before tapering back down. For more severe cases of vertigo, especially those that don’t respond to a first or second-line drug, otolaryngologists said involving a neurologist is always a good idea.