Treatment Evidence in Vestibular Migraine

Vestibular migraine is one of the more common causes of recurrent vertigo, and one of the least well served by treatment evidence. No medication is licensed specifically for it. The preventives used are borrowed from ordinary migraine practice on the reasoning that the underlying condition is the same, and the trial evidence supporting that borrowing is thin.

Vestibular rehabilitation sits outside that problem. It is a structured exercise program rather than a drug, it is already established for other vestibular disorders, and it carries none of the contraindications or side effects that complicate preventive medication. Whether it helps vestibular migraine specifically has been an open question.

A new systematic review and meta-analysis in Otology and Neurotology, from a team at the University of Calgary and the University of British Columbia, pools the studies that have asked it.

What Vestibular Rehabilitation Is

Vestibular rehabilitation is a supervised exercise program delivered by a physical therapist or audiologist with specific training, tailored to what a given person's balance system is doing wrong.

How the Review Worked

The team searched Medline, Embase and Scopus from database inception through May 2025, and added citation searching on top. The review followed PRISMA 2020 reporting guidance.

Inclusion required adults with vestibular migraine diagnosed by ICHD-3 criteria or an equivalent, receiving vestibular rehabilitation, with a patient-reported outcome measured. The two outcomes specified were the Dizziness Handicap Inventory and the Activities-specific Balance Confidence scale. Pooling used mixed-effects modeling.

The Pooled Result

All seven studies showed DHI improvement after vestibular rehabilitation. The individual study effects ranged from a 10.57 point reduction at the smallest to a 44.7 point reduction at the largest.

Pooled across all seven, the reduction was 23.97 points (95% CI 14.62 to 33.31, p less than 0.0001). That sits above the roughly 18 point threshold usually used for clinical meaningfulness, and the confidence interval's lower bound of 14.62 sits just below it.

The Heterogeneity Problem

An I-squared of 96% is about as high as this statistic goes. It means almost all of the variation between the study results comes from real differences between the studies rather than from chance.

The funnel plot asymmetry points in a separate unhelpful direction. Asymmetry of that kind is usually taken to mean that small studies with large positive results are overrepresented, either because small negative studies were never published or because smaller studies are more prone to overestimating effects. When that pattern is present the pooled figure is likely to sit above the truth.

Both observations affect the size of the estimate rather than its direction. All seven studies found improvement in dizziness handicap. How large that improvement is remains uncertain.

Dizziness Handicap and Balance Confidence

The two outcome measures moved differently. Dizziness handicap improved past the clinical threshold, while balance confidence improved without reaching it.

These scales ask different questions. The DHI asks how much dizziness interferes with living. The ABC asks how confident a person feels about staying upright during specific tasks. A result where the first moves and the second does not suggests the benefit lies more in the impact of symptoms than in measurable steadiness.

That fits how vestibular migraine tends to present. Attacks are episodic, and between them balance is often objectively normal, so there may be less room for a balance measure to improve. The burden reported by patients is usually about the disruption of the episodes and the avoidance built up around them, which is closer to what the DHI captures.

What to Do With This

The evidence base here is seven studies and 272 people, graded moderate to low. That supports raising vestibular rehabilitation as an option to discuss, short of a settled recommendation.

Access is its own question. Vestibular rehabilitation requires a therapist with specific training, and availability varies by region and insurance in ways that have nothing to do with the evidence.

For anyone tracking whether it is working, the DHI is the measure these studies used, it is freely available, and repeating it before starting and again at the end of a program gives a number to compare rather than an impression.

Key Takeaways

Vestibular migraine has fewer treatment options than its prevalence warrants, and most of what gets used is inherited from migraine practice without vestibular-specific trials behind it. This review puts a number on one non-drug option and is candid that the number rests on very little.

The authors close by calling for large prospective studies with standardized rehabilitation protocols and outcome measures. The current evidence base is seven small studies with an I-squared of 96%.