Pharmacological management of vestibular migraine of childhood in a pediatric vestibular program.

OBJECTIVE

To compare the efficacy and tolerability of medications used to treat pediatric vestibular migraine.

METHODS

This retrospective analysis at a quaternary pediatric vestibular program identified patients ≤18 years old with vestibular migraine of childhood (VMC), probable VMC, or recurrent vertigo of childhood per the 2021 Bárány Society diagnostic criteria. Preventative medications included cyproheptadine, propranolol, topiramate, amitriptyline, nortriptyline, venlafaxine, and duloxetine. Rescue medications included triptans, nonsteroidal anti-inflammatory drugs (NSAIDs), and meclizine. Patient characteristics were obtained. Changes in headache and dizziness symptoms were classified as no improvement, minor improvement, major improvement, or complete resolution. Generalized estimating equations compared the proportion of patients with at least major improvement for each medication.

RESULTS

160 patients were included [mean (SD) age 12.8 (3.9) years; 70% female]. Among preventatives, the proportion of patients who experienced at least major improvement was greatest for topiramate, with a significant difference relative to the lowest performer, cyproheptadine, for dizziness (67.6% vs. 37.5%, p < 0.001) and headache (69.4% vs. 37.5%, p < 0.001). Among rescue medications, triptans outperformed meclizine in dizziness (40.0% vs. 12.5% p = 0.048) and headache (42.7% vs. 5.6%, p = 0.019), and outperformed NSAIDs in dizziness (40.0% vs. 11.5%, p = 0.021). Age, sex, anxiety, depression, or concussion history did not influence treatment outcomes for any medication.

CONCLUSIONS

For pediatric vestibular migraine prevention, topiramate showed superior improvement in dizziness and headache with acceptable tolerability. Triptans performed the best among rescue medications. This highlights topiramate as a potential first line preventative and supports triptans in treating pediatric vestibular migraine attacks.