Nystagmus and Vertigo in Acute Vestibular Migraine Attacks: Response to Non-Invasive Vagus Nerve Stimulation

Vestibular migraine (VM) is the most common neurologic cause of vertigo in adults, but there are no currently-approved rescue therapies. This study describes the benefits of non-invasive vagus nerve stimulation (nVNS) on vertigo, headache, and nystagmus during VM attacks.

Case series of four VM patients who were evaluated during acute VM episodes in a tertiary referral neurology clinic between February 2019 and January 2020. They underwent bedside neuro-otologic examination, and graded the severity of vertigo and headache using a 10-point visual-analog scale (VAS; 0-no symptoms, 10-worst ever symptoms), before and 15 minutes after nVNS.

Average vertigo severity was 5 (median 4.5) before, and 1.5 (median 0.5) after nVNS. Mean headache severity (three patients) before treatment was 4 (median 4), and 0.7 (median 0) after. Spontaneous right-beating nystagmus (Patient 1) nystagmus, upbeat nystagmus (Patient 2), and positional nystagmus (Patient 3) resolved with nVNS. Baseline left-beating nystagmus in Patient 4 from previous vestibular neuritis damped during acute VM but returned to baseline following nVNS. In all four patients, ictal nystagmus resolved, and examination findings returned to baseline.

This study suggests nVNS may ameliorate vertigo and headache, as well as nystagmus associated with VM attacks. Larger, sham device-controlled studies are needed to elucidate the benefits of nVNS in VM.