Written by Dr Ray Bose, Auckland neurologist and migraine and headache specialist
Vestibular migraine is a common yet often underdiagnosed neurological condition that combines the symptoms of vertigo or dizziness with those of migraine. It can significantly impact quality of life, often affecting balance, mobility and daily functioning.
This article aims to provide patient-friendly information about vestibular migraine, its symptoms, how common it is and the treatment options available in New Zealand.
How common is vestibular migraine?
Vestibular migraine affects approximately 1% of the general population and is thought to account for about 10% of all people presenting to dizziness clinics. It’s more common in women than men, typically emerging in early to mid-adulthood, though it can also affect children and older adults.
Vestibular migraine symptoms
People with vestibular migraine may experience a combination of the following symptoms:
- spontaneous or positional vertigo (a sensation of spinning or movement)
- imbalance or unsteadiness
- nausea or vomiting
- visual motion sensitivity
- head pressure or headache (though some may not experience headache)
- light or sound sensitivity (photophobia or phonophobia)
- brain fog or difficulty concentrating
- aura symptoms (such as visual disturbances or tingling).
Symptoms can last from minutes to hours and may or may not occur alongside a headache. Attacks can be sporadic or frequent, and the condition can be misdiagnosed as benign paroxysmal positional vertigo (BPPV), Ménière’s disease or anxiety.
Diagnosis
Diagnosis is clinical, based on the International Classification of Headache Disorders (ICHD-3) criteria. There’s no definitive test. A careful history, neurological examination and exclusion of other causes are crucial.
Management strategies
Treatment of vestibular migraine involves a combination of lifestyle modifications, acute symptom relief and preventive medications.
Lifestyle and non-medication approaches
- Regular sleep and meals
- Reducing stress
- Vestibular rehabilitation therapy (VRT)
- Limiting caffeine and alcohol
- Trigger identification (e.g. specific foods, hormonal changes)
Acute medications (used during attack)
- Triptans (e.g. sumatriptan, rizatriptan)
- NSAIDs (e.g. ibuprofen, diclofenac)
- Antiemetics (e.g. prochlorperazine)
These are funded in New Zealand.
Preventive medications (for frequent/severe episodes)
- Amitriptyline
- Nortriptyline
- Propranolol
- Metoprolol
- Candesartan
- Topiramate
- Lamotrigine
These are funded in New Zealand.
Newer therapies and emerging options
Calcitonin gene-related peptide (CGRP) monoclonal antibodies (e.g. galcanezumab (Emgality), erenumab (Aimovig))
These target the calcitonin gene-related peptide pathway involved in migraine pathophysiology.
- Shown to reduce migraine days and improve quality of life.
- Emerging evidence suggests benefit in vestibular migraine.
- Not funded in New Zealand; may be accessed via private prescription. More information here
GammaCore vagal nerve stimulation
- A handheld device that stimulates the vagus nerve.
- Non-invasive and may help reduce frequency and severity of vestibular migraine attacks.
- Not funded; available through some specialist clinics in New Zealand. More information here
The role of flunarizine
Flunarizine is a calcium channel blocker with evidence supporting its use in vestibular migraine prevention. It’s widely used in Europe and parts of Asia.
- Multiple studies have shown significant reduction in vestibular symptoms and migraine frequency.
- Generally well tolerated, though sedation and weight gain are possible side effects.
Flunarizine is not funded in New Zealand. Flunarizine can be prescribed by a GP as a section 29 medication. You may have to talk with your pharmacy about ordering flunarizine from overseas through CDC Pharmaceuticals or OneLink.
Flunarizine is available in 5mg or 10mg. Prices may vary, from what we know from a wholesaler, 10mg should be approximately $90 for a one-month supply.
Vestibular migraine is a real and treatable condition. With a combination of lifestyle adjustments, appropriate medications and emerging therapies, many people can achieve significant relief. People are encouraged to work with their GP or neurologist to explore the best treatment strategy for them.
References
- Lempert T, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012.
- Furman JM, et al.Vestibular migraine: clinical aspects and pathophysiology. Lancet Neurol. 2013.
- Lepcha A, Amalanathan S, Augustine AM, Tyagi AK, Balraj A. Flunarizine in the prophylaxis of migrainous vertigo: a randomized controlled trial. Eur Arch Otorhinolaryngol. 2014
- Russo CV, Saccà F, Braca S, Sansone M, Miele A, Stornaiuolo A, De Simone R. Anti-calcitonin gene-related peptide monoclonal antibodies for the treatment of vestibular migraine: A prospective observational cohort study. Cephalalgia. 2023
- Smyth D, Britton Z, Murdin L, Arshad Q, Kaski D. Vestibular migraine treatment: a comprehensive practical review. Brain.
- Pharmac. New Zealand Pharmaceutical Schedule. www.pharmac.govt.nz
