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Pharmacotherapy failure and progression to botulinum toxin injection in vestibular migraine

Published online by Cambridge University Press:  27 July 2020

Y F Liu
Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
D Macias
Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
L Donaldson
Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
J R Dornhoffer
Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
H G Rizk*
Department of Otolaryngology – Head and Neck Surgery, Medical University of South Carolina, Charleston, USA
Author for correspondence: Dr Habib G Rizk, 135 Rutledge Avenue, MSC 550, Charleston, SC29425, USA E-mail: Fax: +1 843 792 0546



Given the lack of evidence on patients with medically refractory vestibular migraine, this study aimed to identify factors associated with pharmacotherapy failure and progression to botulinum toxin injection in vestibular migraine.


A retrospective cohort study was conducted on definite vestibular migraine patients from September 2015 to July 2019 who completed the Dizziness Handicap Inventory at least six weeks apart..


The study comprised 47 patients (mean age = 50.2 ± 15.8 years), with a mean follow-up time of 6.0 ± 6.0 months. The mean pre-treatment Dizziness Handicap Inventory score was 57.5 ± 23.5, with a mean reduction of 17.3 ± 25.2 (p < 0.001) at last follow up. Oscillopsia (r = 0.458, p = 0.007), failure of first medication (r = 0.518, p = 0.001) and pre-treatment Dizziness Handicap Inventory question 15 (an emotional domain question) score (r = 0.364, p = 0.019) were the only variables significantly correlated with progression to botulinum toxin injection.


Motion hypersensitivity, failure of first medication, and fear of social stigmatisation suggest a decreased treatment response. These symptoms may require more aggressive treatment at an earlier stage.

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Copyright © The Author(s), 2020. Published by Cambridge University Press

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Dr H G Rizk takes responsibility for the integrity of the content of the paper


Formeister, EJ, Rizk, HG, Kohn, MA, Sharon, JD. The epidemiology of vestibular migraine: a population-based survey study. Otol Neurotol 2018;39:1037–44CrossRefGoogle ScholarPubMed
Huang, TC, Wang, SJ, Kheradmand, A. Vestibular migraine: an update on current understanding and future directions. Cephalalgia 2020;40:107–21CrossRefGoogle ScholarPubMed
Lempert, T, Neuhauser, H. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol 2009;256:333–8CrossRefGoogle ScholarPubMed
Lempert, T, Olesen, J, Furman, J, Waterston, J, Seemungal, B, Carey, J et al. Vestibular migraine: diagnostic criteria. J Vestib Res 2012;22:167–72CrossRefGoogle ScholarPubMed
Lauritsen, CG, Marmura, MJ. Current treatment options: vestibular migraine. Curr Treat Options Neurol 2017;19:38CrossRefGoogle ScholarPubMed
Power, L, Shute, W, McOwan, B, Murray, K, Szmulewicz, D. Clinical characteristics and treatment choice in vestibular migraine. J Clin Neurosci 2018;52:50–3CrossRefGoogle ScholarPubMed
Beh, SC, Masrour, S, Smith, SV, Friedman, DI. The spectrum of vestibular migraine: clinical features, triggers, and examination findings. Headache 2019;59:727–40CrossRefGoogle ScholarPubMed
Jacobsen, GP, Newman, CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg 1990;116:424–7CrossRefGoogle Scholar
Mutlu, B, Serbetcioglu, B. Discussion of the Dizziness Handicap Inventory. J Vestib Res 2013;23:271–7CrossRefGoogle ScholarPubMed
Van De Wyngaerde, KM, Lee, MK, Jacobson, GP, Pasupathy, K, Romero-Brufau, S, McCaslin, DL. The component structure of the Dizziness Handicap Inventory (DHI): a reappraisal. Otol Neurotol 2019;40:1217–23CrossRefGoogle ScholarPubMed
Fernandez M, Maldonado, Birdi, JS, Irving, GJ, Murdin, L, Kivekas, I, Strupp, M. Pharmacological agents for the prevention of vestibular migraine. Cochrane Database Syst Rev 2015;(6):CD010600Google Scholar
Beh, SC. Vestibular migraine: how to sort it out and what to do about it. J Neuroophthalmol 2019;39:208–19CrossRefGoogle Scholar
Bikhazi, PJC, Ruckenstein, MJ. Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness. Am J Otol 1997;18:350–4Google ScholarPubMed
Szok, D, Csati, A, Vecsei, L, Tajti, J. Treatment of chronic migraine with onabotulinumtoxinA: mode of action, efficacy and safety. Toxins (Basel) 2015;7:2659–73CrossRefGoogle ScholarPubMed
Tassorelli, C, Sances, G, Avenali, M, De Icco, R, Martinelli, D, Bitetto, V et al. Botulinum toxin for chronic migraine: clinical trials and technical aspects. Toxicon 2018;147:111–15CrossRefGoogle ScholarPubMed
Herd, CP, Tomlinson, CL, Rick, C, Scotton, WJ, Edwards, J, Ives, NJ et al. Cochrane systematic review and meta-analysis of botulinum toxin for the prevention of migraine. BMJ Open 2019;9:e027953CrossRefGoogle ScholarPubMed
Escher, CM, Paracka, L, Dressler, D, Kollewe, K. Botulinum toxin in the management of chronic migraine: clinical evidence and experience. Ther Adv Neurol Disord 2017;10:127–35CrossRefGoogle ScholarPubMed
Bruloy, E, Sinna, R, Grolleau, JL, Bout-Roumazeilles, A, Berard, E, Chaput, B. Botulinum toxin versus placebo: a meta-analysis of prophylactic treatment for migraine. Plast Reconstr Surg 2019;143:239–50CrossRefGoogle ScholarPubMed
Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia 2018;38:1211CrossRefGoogle Scholar
Naegel, S, Matharu, M, Obermann, M. Treatment options for vestibular migraine. US Neurology 2016;12:3942CrossRefGoogle Scholar
Bender, MB. Oscillopsia. Arch Neurol 1965;13:204–13CrossRefGoogle ScholarPubMed
Morland, AB, Bronstein, AM, Ruddock, KH, Wooding, DS. Oscillopsia: visual function during motion in the absence of vestibulo-ocular reflex. J Neurol Neurosurg Psychiatry 1998;65:828–35CrossRefGoogle ScholarPubMed
Anson, ER, Gimmon, Y, Kiemel, T, Jeka, JJ, Carey, JP. A tool to quantify the functional impact of oscillopsia. Front Neurol 2018;9:142CrossRefGoogle ScholarPubMed
Jones, W, Silkworth, W, Dusto, N, Pelak, VS, Berliner, J, Buard, I et al. Central visual oscillopsia: case report and review of the literature. Cogn Behav Neurol 2018;31:8995CrossRefGoogle ScholarPubMed
Lucieer, F, Vonk, P, Guinand, N, Stokroos, R, Kingma, H, van de Berg, R. Bilateral vestibular hypofunction: insights in etiologies, clinical subtypes, and diagnostics. Front Neurol 2016;7:26CrossRefGoogle ScholarPubMed
Tfelt-Hansen, P, Pascual, J, Ramadan, N, Dahlof, C, D'Amico, D, Diener, HC et al. . Guidelines for controlled trials of drugs in migraine: third edition. A guide for investigators. Cephalalgia 2012;32:638Google ScholarPubMed
Smelt, AF, Louter, MA, Kies, DA, Blom, JW, Terwindt, GM, van der Heijden, GJ et al. What do patients consider to be the most important outcomes for effectiveness studies on migraine treatment? Results of a Delphi study. PLoS One 2014;9:e98933CrossRefGoogle ScholarPubMed
Lipton, RB, Munjal, S, Buse, DC, Fanning, KM, Bennett, A, Reed, ML. Predicting inadequate response to acute migraine medication: results from the American Migraine Prevalence and Prevention (AMPP) study. Headache 2016;56:1635–48CrossRefGoogle ScholarPubMed
Darnall, BD, Sturgeon, JA, Cook, KF, Taub, CJ, Roy, A, Burns, JW et al. Development and validation of a daily pain catastrophizing scale. J Pain 2017;18:1139–49CrossRefGoogle ScholarPubMed
Ten Voorde, M, van der Zaag-Loonen, HJ, van Leeuwen, RB. Dizziness impairs health-related quality of life. Qual Life Res 2012;21:961–6CrossRefGoogle ScholarPubMed
Dowson, AJ, Tepper, SJ, Baos, V, Baudet, F, D'Amico, D, Kilminster, S. Identifying patients who require a change in their current acute migraine treatment: the Migraine Assessment of Current Therapy (Migraine-ACT) questionnaire. Curr Med Res Opin 2004;20:1125–35CrossRefGoogle ScholarPubMed
Liu, YF, Locklear, TD, Sharon, JD, Lacroix, E, Nguyen, SA, Rizk, HG. Quantification of cognitive dysfunction in dizzy patients using the neuropsychological vertigo inventory. Otol Neurotol 2019;40:e723–31CrossRefGoogle ScholarPubMed