Medication,  Migraine,  Vertigo,  Vestibular Migraine

How to Use Vestibular Suppressants to Best Treat Vestibular Migraine

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Living with a balance disorder like vestibular migraine interferes with our quality of life. Working, driving, our ability to participate in activities with friends and family and function in a way that allows us to simply enjoy life are all inhibited by uncomfortable and at times disabling symptoms. Because of this it’s important to seek treatment from a qualified vestibular specialist who can decipher between similar symptoms caused by very different balance disorders and begin proper treatment. Treatment depends on the underlying cause. But, the three cornerstone treatments specialists typically recommend to alleviate distressing vestibular symptoms are vestibular rehabilitation therapy, lifestyle changes and medication that may include vestibular suppressants.

Vestibular suppressants for vertigo

I’d like to say vestibular suppressants eliminate vertigo, restore our natural balance, come with minimal side effects and refrain from hindering the natural process of vestibular compensation. Unfortunately, that’s not exactly the most common outcome of vestibular suppressants. They don’t address the underlying cause of your dizziness & vertigo.

Often, the mild ones are not enough to work and the strong ones can come along with significant side effects. What vestibular suppressants can do is dampen your symptoms of dizziness and vertigo especially when you are in vestibular crisis.

If you have constant dizziness due to vestibular migraine, a vestibular suppressant is likely not the best first choice to manage it long term. Lifestyle changes, supplements, vestibular rehabilitation therapy and preventative medications are often needed for long term disease management to bring dizziness under control.

Instead, vestibular suppressants are sometimes used short term while you wait for your multi modal treatment plan to kick in. Then they are often used as a rescue medication to manage crisis symptoms of vertigo and imbalance attacks. They are also often used short term at disease onset to help you feel well enough to begin other treatments like vestibular rehabilitation therapy. In the world of medication short term is typically defined as one to three months.

**While Migraine Strong writes about the latest in migraine treatments, this is not medical advice. We are patient educators and all information you read should be discussed with your doctor.

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Vestibular suppressant medication

There are three major medication groups of vestibular suppressants: anticholinergics, antihistamines, and benzodiazepines. Vestibular research appears to be in its infancy and I mean little baby newborn infancy. Nearly every publication I read stated that the exact function of how vestibular suppressants work is unclear, but they appear to interrupt communication of the neurotransmitters involved in the three part vestibular system.

Anticholinergics

If you have a vestibular disorder then you know we often have an extreme intolerance to movement. Anticholinergics most commonly prescribed as a scopolamine patch helps to increase tolerance to motion. Since it’s a milder vestibular suppressant it’s also a less sedating option. This may be useful to reduce sensitivity to movement for those with chronic symptoms, especially those who need to carry on with activities and work. This is also a good option for occasions when you expect increased motion and can place the patch on ahead of time, like while traveling.

Antihistamines

Dimenhydrinate (Dramamine), Diphenhydramine (Benadryl), and Meclizine (Bonine) are often recommended treatments for dizziness and motion sickness. Also, generally considered a milder vestibular suppressant, they can take the edge off attacks especially when paired with anti-nausea medication.

Many members of Migraine Strong with vestibular migraine have reported that they are ineffective in treating their vertigo & dizzy attacks though. Antihistamines do not seem to be strong enough to be effective in managing vertigo for everyone, but can be effective in managing dizziness and motion sickness even after it’s begun for some. The role histamine plays in the vestibular process is uncertain and needs more research.

Benzodiazepines

Medications in this class are commonly used to treat anxiety and are currently recognized as a drug of addiction and abuse. This class of medication is very effective in treating vertigo, but may be hard to get as doctors seem to passionately lean for or against using benzodiazepines for vestibular patients.

While benzos can be helpful for those with comorbid anxiety, that’s not their intended use for those with balance disorders alone. Just like antihistamines mentioned above are not intended to treat allergies for vestibular patients, benzos (for vestibular disorders alone) are not intended to treat anxiety. They are considered a strong vestibular suppressant medication and are used as such.

As a side note, I think it’s time we end migraine stigma and acknowledge those with migraine disease are not drug seekers. We have a neurological condition that comes with disabling symptoms of pain, vertigo and more. Many medications are used off label to treat these distressing symptoms. Excluding the newest drugs on the market, most migraine preventative medications were all intended to treat other conditions. The same is true here.

Generally, the stronger the vestibular suppressant, the stronger its sedating effects. Benzos are effective because they are strong vestibular suppressants. That means they also come with the most side effects and should be used with the most caution.

Side effects

While the medications above have been labeled mild vs strong, all should be used with caution and under the supervision of a vestibular specialist. They should not be used with children, in pregnancy or while drinking alcohol. Special caution should be considered in the elderly as they increase the risk of falling.

Vestibular suppressant medications may cause:

  • Addiction
  • Cognitive deficits
  • Dependence
  • Disorientation
  • Drowsiness
  • Habituation
  • Hallucinations
  • Impaired memory
  • Impaired vestibular compensation  
  • Increased risk of car accidents
  • Increased risk of falling
  • Sedation

Some of the ways vestibular suppressants are used to treat vestibular migraine

Vestibular suppressant medications are often used acutely to treat an attack. In Migraine Strong, we define them not as an abortive or a preventative medication, but as a rescue medication. Rescue medications do not prevent or eliminate attacks. Rather, they make us more comfortable as we move through one. If you have been diagnosed with vestibular migraine, your doctor has likely reviewed a detailed treatment plan in all three areas. Preventative, Abortive and Rescue.

Occasionally in chronic cases vestibular suppressants are used preventatively. However, many publications warn against this type of use and claim it increases the risk of unpleasant side effects including sedation and inhibits vestibular compensation. More on that later.

These risks create the need to control vertigo, dizziness & imbalance to be weighed against these negative effects. Treating the underlying cause of your dizziness or vertigo through a multi-modal preventative & abortive treatment plan is the preferred dogma over suppressing symptoms through your rescue plan alone.

Considering this, some doctors may prefer to use a stepped vestibular suppressant treatment beginning with milder options like meclizine before prescribing a benzo. One of the most prominent vestibular specialists in the country, Dr. Timothy Hain, “the dizzy doctor” at Northwestern Memorial Hospital, states benzos are best used in small doses and for a limited amount of time (a month) although some patients require a small dose on a daily basis.

The most common use of vestibular suppressants we see from members of the Migraine Strong community

  1. A stepped approach- Mild vestibular suppressants are tried before stronger vestibular suppressants like Valium.
  2. Low dose- A very low dose is tried before more sedating, larger doses.
  3. Short Term- At disease onset (or flare) when symptoms of dizziness, imbalance and vertigo are continuous, vestibular suppressants may be prescribed daily for a short period of time (a month or two) to dampen dizzy symptoms while you wait for your preventative & abortive treatment plans to be effective.
  4. As a rescue medication- A certain number of pills (decided between you and your doctor) may be prescribed each month to used during vestibular crisis. Crisis includes vestibular migraine attacks that come with vertigo, dizziness and imbalance. Remember, your rescue medication should dampen dizziness & help make you more comfortable as you move through your attack & wait for your abortive treatment to be effective.
  5. Occasionally a daily low dose is prescribed for those with chronic daily symptoms.

Will vestibular suppressants hinder vestibular compensation?

In simple terms, vestibular migraine is a hypersensitivity to a stimulus within the central nervous system causing typical migraine symptoms along with dizziness, imbalance and vertigo. Vestibular compensation happens when the brain begins to adapt and account for this hyper-sensitivity until it’s less or no longer provoked by the stimulus.

With very little data to support it, nearly every publication warns that long term use of vestibular suppressants can hinder the central nervous system’s natural process of vestibular compensation and make symptoms of imbalance worse or prolonged. One glaring standout was an informative article by Dr. Hain reviewing the data on benzodiazepines for dizziness. He states that in his practice, he has never seen a patient fail to compensate while using a vestibular suppressant.

He does not recommend all benzodiazepines for dizziness though. Alprazolam (Xanax) and Chlordiazepate are not recommended because of how long (or short) they last in our system. It wears off more quickly than others leaving patients to take it more often making it more likely to lead to dependency and addiction issues. Here are the benzodiazepines and dose recommendations he does mention in his article:

DrugLowest effective doseTime constant in the blood“Low dose” to manage chronic vertigo
Lorazepam0.512-18 hours.0.5 mg twice/day
Clonazepam0.530 hours0.5 mg twice/day
Diazepam2 mgseveral, up to 24 hours.2 mg twice/day

Despite his skepticism on vestibular suppressants ability to hinder vestibular compensation, Dr. Hain still clearly states benzodiazepines should not be “first treatment” for dizziness, but rather should be part of a “stepped” protocol beginning with milder suppressants (like meclizine) and should be used low dose and short term (he mentions one month).

Should I take vestibular suppressants during vestibular testing?

Vestibular suppressants interfere with vestibular testing. Vestibular signals will be dampened and their sedative effects could hinder a patient from being able to perform the motor tasks asked of them. Hindrance may be a result of concentration deficits as well as motor abilities. For these reasons most specialists recommend discontinuing their use before vestibular testing. This will of course ultimately be determined on an individual basis by you and your doctor.

My personal experience with vestibular suppressant medication

When I got sick, it was months until I received proper diagnosis along with an effective treatment plan. Unfortunately, I received a diagnosis right as my FMLA, which only allows 3 months of job protection, ran out. So I had to return to work still drowning in symptoms. My employer graciously allowed me to work part time from home for one extra month while I waited for my treatment plan to start working which ultimately saved my job. Along with supplements, lifestyle changes, preventative medication and vestibular rehabilitation therapy, my specialist prescribed a benzo to help me dampen my dizziness enough to allow me to function as I returned to work.

How I effectively used Valium for vertigo

Since I knew valium was a potent and controversial medication, I was very aware of how I tried it. Like many with VM, I am very sensitive to medications. So the first time I took it, I cut the prescribed dose in half. Even at half dose I still felt very tired and spacey so I decided to cut my dose down even further. After talking to my doctor, I cut my 2mg pill into quarters and took just a quarter once or sometimes twice a day. That was enough to dampen my symptoms without making me feel off. (Granted I weighed under 100lbs pounds at the time due to the weight loss I suffered from being nauseas and dizzy every day for months).

I did that for about 2 months while I waited for my preventative medication to start working. Around week eight on my preventative medication, my dizziness began to fade. At that low dose, I stopped Valium with no difficulty at all. Now use it solely as a rescue medication. I only need valium for vertigo attacks or flares of dizziness that happen just a few times a year. Meaning I now only use it only as a rescue medication when I’m in vestibular crisis.

As someone diagnosed with both vestibular migraine and Meniere’s disease I feel reassured knowing I have this vestibular rescue medication available to reach for if I really need it. Yet, I almost never have to actually reach for it. My symptoms are well controlled through my preventative treatment plan. Just the reassurance of knowing I can if I need to is enough.

My specialist feels it’s cruel to make vestibular patients go without a rescue medication option and I agree with him. I’m grateful he trusts me to use it responsibly. When used low dose and short term and then only as a rescue medication, I believe vestibular suppressants have an important usefulness in managing vestibular symptoms as part of a well-rounded treatment plan.

Tips on talking with your doctor about Valium for vertigo (or other benzos)

Did you know that the popular Rolling Stone’s song, Mother’s Little Helper, was about Valium? The word “hesitant” doesn’t quite describe the reaction of many doctors when a patient specifically asks for a medication that is classified as a controlled substance. These medications, like opioids are highly regulated.

In general, if your doctor does not specialize in treating vestibular disorders, you should expect him or her to be skeptical of requesting Valium (or other benzos) for temporary treatment of your vertigo attacks. This is one more reason why I always encourage people with vestibular disorders to see a doctor with the best credentials and training.

But, not all of us have access to vestibular specialists. If you expect that you will have to ask for a benzo, bring resources with you that explain how and why the medication may help you. Being familiar with Dr. Hain’s article on benzodiazepines for vertigo should provide the information you need to have an educated discussion.

Be prepared to accept a prescription for just a few pills a month rather than a 30 day supply. If a 30 day supply is written you may be expected to use it over several months rather than obtaining a refill monthly. This is sometimes a good compromise between doctor and patient to build trust that abuse is off the table. Understand that if you are seeing your specialist via telehealth, your doctor may not be allowed to prescribe a benzodiazepine in your state. Having your specialist communicate with your local primary care physician to carry out his treatment recommendations can be helpful.

Reviewing a detailed plan with your doctor on how to use your medication is important. Everyone reacts differently to benzos and they are not meant for every patient. If you’ve experienced addiction issues with other medications or substances, plan to talk openly with your doctor about it. This will allow the best personal treatment plan for you as an individual. Also know the first medication you try may be too sedating, ineffective or just not the right fit for you. If this happens plan to talk openly with your doctor about other options.

Be prepared to accept the recommendation of your doctor over anything you read here. Our goal is to educate on treatment options and not to recommend any specific treatment for you. We find value in the discussion, but absolutely acknowledge your doctor knows much more about your proper care than we ever could. Place the value in your doctor’s opinion over anything you read on the internet.

Doctor Madison Oak’s thoughts on vestibular suppressants:

Because we care so much about bringing you accurate medical information we asked Madison Oak, Doctor of Physical Therapy who specializes in vestibular disorders to share her thoughts on vestibular suppressants. Here is her response:

VESTIBULAR SUPPRESSANTS 

Being prescribed a vestibular suppressant as a first line of treatment for dizziness occurs frequently, however it’s not necessarily because it’s the best choice. It’s frequently because many healthcare providers do not know enough about dizziness, vertigo, and disequilibrium to accurately assess, diagnose, and treat the condition. There are some times that vestibular suppressants can be useful, but taking them all the time is not helpful, and can actually hinder your progress and recovery. 

Vestibular suppressants are made to do one thing: suppress your vestibular system. In theory, this is a great idea; if it’s suppressed you won’t feel dizzy. However, from what I have found as a vestibular therapist, patients often become tired, irritated, and depressed – and it usually doesn’t even help the dizziness. There are a few reasons this may be helpful, but it is usually not the best course of action for dizziness. 

If a vestibular suppressant works for you, it might be exactly what you need during an attack. If you are a person living with vestibular migraine, Meniere’s disease, or other chronic vestibular disorder you may have a prescription for Meclizine to help get through the attacks themselves. When you are having an attack, you should do anything you can to make yourself feel safe and comfortable. Things like ginger, zofran, meclizine, deep breathing, and sparkling water may be on that list. And that’s completely okay. Do anything you can to be as comfortable as possible. Additionally, if you are traveling and motion sensitive, it’s usually okay to take Meclizine then too.  

However, for the most part, suppressants actually do more harm than good. Taking a vestibular suppressant, such as Meclizine, will dampen the response of your vestibular system and make it weaker over time. Strengthening your vestibular system is incredibly important if you have a vestibular disorder. Vestibular strengthening is done through movement, vestibular rehabilitation, and time. Taking a vestibular suppressant hinders this process as you are not able to stimulate the system in the way you would normally to strengthen it. 

People who go to the emergency department with the complaint of dizziness are most frequently prescribed Meclizine. They are also hopefully also given a prescription for vestibular rehabilitation therapy (VRT). When the patient arrives at their VRT evaluation, they have usually been taking Meclizine a few times a day since their trip to the ED. When this happens, the physical therapist is not able to accurately assess and diagnose the vestibular dysfunction. Because of the vestibular suppressants, your eyes will not produce nystagmus as they would in a normal evaluation, and things that may usually make you dizzy also will not produce a response.

Instead of vestibular suppressants, there are many other prescription and nonprescription ways to to prevent and treat vestibular disorders. Eating a well-rounded diet and avoiding trigger foods, staying hydrated, exercising daily, taking preventative medications and more are all excellent ways to prevent dizziness and vestibular attacks without a vestibular suppressant. Your treatment pie is so important here! 

Because I am not your physician or other doctor, this is not medical advice. However, if you do seem to resonate with this, please bring it up with your doctor so you can have an informed chat about your best plan of care!

You can find Doctor Oak on thevertigodoctor.com and on Instagram by searching The Vertigo Doctor.

Helpful Resources:

https://dizziness-and-balance.com/treatment/drug/drugrx.html

https://dizziness-and-balance.com/treatment/drug/benzodiazepines_vertigo.html

VeDA Vestibular Injury

Harvard Health Publishing Vertigo

VeDA Medication

Medications and Dizziness Fact Sheet

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How to Use Vestibular Suppressants to Best Treat Vestibular Migraine

I was diagnosed with Vestibular Migraine in 2016 and my neurotologist added a Ménière’s Disease mild diagnosis in 2018. I went from being housebound for months to working full time and living an active full life by following the Migraine Strong treatment pie. Preventive medications, the Heal Your Headache Diet and supplements do a lot of the heavy lifting in relieving my symptoms. You can also find me over on The Dizzy Cook blog baking yummy head safe goodies on a guest post each month.

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