Pharmacological interventions for acute attacks of vestibular migraine

Katie E Webster, Afrose Dor, Kevin Galbraith, Luma Haj Kassem, Natasha A Harrington-Benton, Owen Judd, Diego Kaski, Otto R Maarsingh, Samuel MacKeith, Jaydip Ray, Vincent A Van Vugt, Martin J Burton

Research output: Contribution to journalReview article (Academic Journal)peer-review

10 Citations (Scopus)

Abstract

BACKGROUND: Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. The unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used, or proposed to be used, at the time of a vestibular migraine attack to help reduce the severity or resolve the symptoms. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar. OBJECTIVES: To assess the benefits and harms of pharmacological interventions used to relieve acute attacks of vestibular migraine.

SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA: We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing triptans, ergot alkaloids, dopamine antagonists, antihistamines, 5-HT3 receptor antagonists, gepants (CGRP receptor antagonists), magnesium, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) with either placebo or no treatment. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 2 hours, 2 to 12 hours, > 12 to 72 hours. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: We included two RCTs with a total of 133 participants, both of which compared the use of triptans to placebo for an acute attack of vestibular migraine. One study was a parallel-group RCT (of 114 participants, 75% female). This compared the use of 10 mg rizatriptan to placebo. The second study was a smaller, cross-over RCT (of 19 participants, 70% female). This compared the use of 2.5 mg zolmitriptan to placebo. Triptans may result in little or no difference in the proportion of people whose vertigo improves at up to two hours after taking the medication. However, the evidence was very uncertain (risk ratio 0.84, 95% confidence interval 0.66 to 1.07; 2 studies; based on 262 attacks of vestibular migraine treated in 124 participants; very low-certainty evidence). We did not identify any evidence on the change in vertigo using a continuous scale. Only one of the studies assessed serious adverse events. No events were noted in either group, but as the sample size was small we cannot be sure if there are risks associated with taking triptans for this condition (0/75 receiving triptans, 0/39 receiving placebo; 1 study; 114 participants; very low-certainty evidence). AUTHORS' CONCLUSIONS: The evidence for interventions used to treat acute attacks of vestibular migraine is very sparse. We identified only two studies, both of which assessed the use of triptans. We rated all the evidence as very low-certainty, meaning that we have little confidence in the effect estimates and cannot be sure if triptans have any effect on the symptoms of vestibular migraine. Although we identified sparse information on potential harms of treatment in this review, the use of triptans for other conditions (such as headache migraine) is known to be associated with some adverse effects. We did not identify any placebo-controlled randomised trials for other interventions that may be used for this condition. Further research is needed to identify whether any interventions help to improve the symptoms of vestibular migraine attacks and to determine if there are side effects associated with their use.

Original languageEnglish
Article numberCD015322
Number of pages45
JournalCochrane Database of Systematic Reviews
Volume4
Issue number4
DOIs
Publication statusPublished - 12 Apr 2023

Bibliographical note

Funding Information:
This project was supported by the National Institute for Health Research, via Cochrane Infrastructure, Cochrane Programme Grant or Cochrane Incentive funding to Cochrane ENT, as well as an Evidence Synthesis Programme grant (NIHR132217). The views and opinions expressed therein are those of the authors and do not necessarily reflect those of the Evidence Synthesis Programme, NIHR, NHS or the Department of Health. The development of the protocol (including the prioritisation of outcomes) for this review was informed by responses to a survey to encourage patient and public involvement in the review process. The development and distribution of this survey would not have been possible without the support of the Ménière's Society and the Migraine Trust, and the authors wish to thank them for their help. The authors would like to thank Lee Yee Chong for her work on generic text that has been used and adapted (with permission) in the methods section of the review protocol. We would also like to extend our thanks to Frances Kellie and Cochrane Pregnancy and Childbirth for their permission to use and reproduce the Cochrane Pregnancy and Childbirth Trustworthiness Screening Tool in this review. The authors are grateful to Professor Malcolm Hilton for clinical peer review of this systematic review, and to Stella O'Brien for her consumer review. Thanks to John P Carey MD and Pavan S Krishnan for clinical peer review of the protocol, and Iris Gordon, Information Specialist with Cochrane Eyes and Vision, for providing peer review comments on the draft search methods. Our thanks also to Professor Stephen O'Leary for editorial sign-off of the protocol and review. We would also like to thank Yuan Chi, who provided help with translation. Finally, our grateful thanks to Jenny Bellorini, Managing Editor for Cochrane ENT, and Samantha Cox, Information Specialist, without whom the development of this review would not have been possible. Cochrane ENT supported the authors in the development of this review. The following people conducted the editorial process for this article: Sign-off Editor (final editorial decision): Professor Stephen O'Leary, Department of Otolaryngology, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne (Cochrane ENT Editor). Managing Editor (selected peer reviewers, collated peer reviewer comments, provided editorial guidance to authors, edited the article): Jenny Bellorini, Cochrane ENT. Copy Editor (copy editing and production): Jenny Bellorini, Cochrane ENT. Peer reviewers: Professor Malcolm Hilton, Department of ENT, Royal Devon University Foundation Trust (clinical/content review), Stella O'Brien (consumer review). Sign-off Editor (final editorial decision): Professor Stephen O'Leary, Department of Otolaryngology, University of Melbourne, Royal Victorian Eye and Ear Hospital, Melbourne (Cochrane ENT Editor). Managing Editor (selected peer reviewers, collated peer reviewer comments, provided editorial guidance to authors, edited the article): Jenny Bellorini, Cochrane ENT. Copy Editor (copy editing and production): Jenny Bellorini, Cochrane ENT. Peer reviewers: Professor Malcolm Hilton, Department of ENT, Royal Devon University Foundation Trust (clinical/content review), Stella O'Brien (consumer review).

Funding Information:
Infrastructure funding for Cochrane ENT National Institute for Health Research, UK This project is funded by the National Institute for Health Research (NIHR) Evidence Synthesis Programme (NIHR132217). The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

Publisher Copyright:
Copyright © 2023 The Authors. Cochrane Database of Systematic Reviews published by John Wiley & Sons, Ltd. on behalf of The Cochrane Collaboration.

Keywords

  • Adult
  • Female
  • Humans
  • Male
  • Migraine Disorders
  • Anti-Inflammatory Agents, Non-Steroidal/therapeutic use
  • Vertigo/drug therapy
  • Headache
  • Tryptamines

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