Disclosures: Michael Dove, MD: No financial relationships or conflicts of interest

Case Description: Patient presented reporting dizziness 3-5 times per week with each episode lasting hours to days. She described the dizziness as a “rocking sensation”. She denied any associated hearing disturbances, tinnitus, or diplopia. Occasionally, the dizzy spells would be accompanied by squeezing and pulsating headaches. The patient did report associated photophobia, phonophobia, and osmophobia. She was previously diagnosed with chronic migraine and had tried the following preventives with these responses: Amitriptyline (tachycardia), topiramate (sweating), duloxetine (tremors), gabapentin (no response). The patient underwent videonystagmography (VNG) that demonstrated uncompensated vestibular dysfunction. She subsequently tried vestibular therapy with minimal improvement. A trial of onabotulinumtoxinA was initiated utilizing the PREEMPT fixed site, fixed dose pattern for the presumed diagnosis of vestibular migraine for a total of 155 units.

Setting: Multidisciplinary Pain Center

Patient: A 40 year old female with headache and dizziness after viral infection Assessment/

Results: After 4 cycles of onabotulinumtoxinA injections, the patient’s dizziness completely resolved. She became migraine-free for 2 full months with a gradual return of symptoms prior to her next injection. She was able to discontinue vestibular therapy and wean off gabapentin as a preventive medication. The patient returned to the recreational activities she enjoyed, without any issues.

Discussion: As physiatrists, it is important to understand that vestibular migraine is the second most common cause of dizziness with a lifetime prevalence of 0.98%. Unfortunately, this disorder is commonly misdiagnosed. Only 10% of individuals meeting criteria for vestibular migraine are actually given that diagnosis. Furthermore, vestibular migraine is difficult to treat with many patients often being refractory to multiple treatment modalities.

Conclusion: Early recognition of vestibular migraine is paramount in initiating the appropriate treatment, as it can be difficult to manage. While vestibular therapy is the gold standard, we should consider adding onabotulinumtoxinA injections to the treatment algorithm for refractory cases.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/onabotulinumtoxina-for-refractory-vestibular-migraine-a-case-report/