Noninvasive vagus nerve stimulation provided rapid relief of vertigo and headache pain caused by acute vestibular migraine (VM), the most common neurologic cause of vertigo, according to a study using retrospective chart review.
The study of 18 patients (Neurology 2019;93[18]: e1715-e1719), conducted at a single tertiary referral center between November 2017 and January 2019, found noninvasive vagus nerve stimulation (nVNS) reduced vertigo severity in 13 of 14 patients and offered “complete resolution” in two. Mean headache severity improved more than 63% according to the analysis, which included 16 women, but there was no improvement in interictal dizziness.
“I am not sure why interictal dizziness did not improve. I suspect that a single treatment of nVNS may not be sufficient and may require regular treatment over a period of time, similar to chronic migraine,” explained lead author Shin Beh, MD, an assistant professor of neurology and neurotherapeutics at University of Texas Southwestern Medical Center, in Dallas.
“The brainstem houses many nuclei that host connections between the vestibular and vagal systems. Most likely, these nuclei—particularly the nucleus tractus solitaries—explain how nVNS relieves vertigo in VM,” added Dr. Beh, who noted the study came about because “there are no approved treatments for vestibular migraine attacks.
“A number of my patients had VM attacks. Since there were no meds available and because they could not be given sedating medications, I offered nVNS to help with their attacks. It helped to relieve most of the acute VM attacks,” Dr. Beh said.
In the study, the authors wrote: “The timing of nVNS treatment from VM onset was not uniform in our patients. In a clinical trial, it would be ideal to administer nVNS treatment within 20 minutes of VM attack similar to use in migraine headache.”
Peter S. Staats, MD, the chief medical officer of National Spine and Pain Centers in Rockville, Md., called randomized controlled trials “the gold standard. However, they are expensive and time-consuming,” he said.
“A pilot trial, like this, is an excellent way to present early clinical evidence and determine if further clinical trials are necessary. Investigators allowed some latitude on when stimulation was performed. Therapy such as VNS should be initiated earlier in the course of a migraine,” said Dr. Staats, who is also a past president of the American Society of Interventional Pain Physicians and a member of the Pain Medicine News editorial advisory board.
Indeed, Dr. Beh said, “While I am encouraged and excited by the responses in this cohort, we need a clinical trial that accounts for placebo effect, timing of treatment, and possibility and effect of repeat treatment.
“Dizziness is common in migraines,” he added. “VM is the most common neurologic cause of vertigo in adults. Headache specialists will almost invariably encounter patients with VM or dizziness associated with migraine attacks. This study suggests nVNS may be an effective, yet noninvasive and very well-tolerated treatment modality. It adds another therapeutic option to the headache specialist’s treatment armamentarium.”
“This study provides early clinical evidence that therapy can be effective in patients with vertigo and dizziness,” Dr. Staats said. “It showed that almost all of the patients were helped with nVNS. It is great that a therapy such as this is now in the tool box of every neurologist and pain specialist, and that patients with acute pain of migraine have access to it.”
—Sheree Geyer