For migraine associated vertigo, identification and elimination of triggers combined with prophylactic medicines is the most common approach. Patients must be instructed to abstain from common trigger foods, such as chocolate, cheese, smoked meats or fish, alcohol, and foods containing high levels of monosodium glutamate (MSG). If such abstinence leads to a drop in the frequency of headaches, then individual foods can be reintroduced one at a time, to determine if each is a potential trigger food. This requires careful record-keeping of meals and headache attacks, but can be well worth the effort and patients should be greatly encouraged to do this. In some cases, dietary abstinence from certain foods will eliminate the headaches. For others, it appears that while dietary triggers do exist and must be avoided to reduce the frequency of headaches, there still remains an underlying susceptibility to migraines.
When dietary modification has little or no positive effect after a month, patients are started on one of the following: topiramate, verapamil, a long-acting beta-blocker such as propanolol, or an antidepressant such as amitriptyline or venlafaxine depending on gender and situation. The anti-cholinergic compounds amitriptyline and verapamil are especially useful and may help control vertigo independently of whether they are useful for migraine per se. Patients can attempt to control an attack by taking a triptan medication, but results for this are highly variable with one report even suggesting that triptans brought about migraine headache in some individuals whose primary MAV symptoms were vertigo and sensory hyperstimulation. There are reports of severe episodes of MAV being successfully treated by administration of intravenous methylprednisolone. However few if any prospective controlled studies have been done with MAV. While vestibular stabilizing medications may be given acutely, the main treatment remains identification of triggers and prophylaxis with amitriptyline and/or verapamil. Although less common, it should also be noted that dizziness can be secondary to anxiety disorders or major depression, both of which also have an increased frequency among migraine patients, in which case venlafaxine treatment may be attempted.
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