As migraine is so common in the general population, chance co-occurrence with an independent vestibular condition has always to be considered, actively explored and ruled out, as they require a different treatment. If left with a condition of episodic vertigo unexplained by other specified vestibular disorders, the question of diagnostic certainty of VM arises. In the appendix of the latest classification of headache disorders, only the entity of definite VM is included, whereas in the Bárány Society’s definition, also an entity of probable VM is included [13]. Beyond these two entities, there are quite a few patients with episodic vertigo not fulfilling those criteria nor those for other diseases (like Menière’s or TIAs), so they can only receive a diagnosis of “benign recurrent vertigo” NOS (not otherwise specified). So far it is not known how important for the treatment choice the distinction of these three entities is; future research will need to address this question.

A first obstacle is usually the acceptance by the patient of the diagnosis of VM. As VM is still a controversial diagnosis not generally accepted in the medical community, patients are often surprised at the announcement of the diagnosis and have usually been confronted with competing and contradictory interpretations of their symptoms. Although migraine is part of general public knowledge, recognizing headache as migraine is still a problem and even more so for VM. A main hurdle, which is probably also a reason why physicians often miss the diagnosis, is when most attacks of vertigo are not accompanied by headache. Additionally, the diagnosis is syndromic, without an available independent diagnostic standard, and test abnormalities are, if present at all, mild and unspecific. Patients’ scepticism about the diagnosis will impact on their adherence of treatment recommendations.

Another barrier to patient adherence to treatment is the kind of drugs usually used. As many were originally developed for other indications, patients are often taken aback by the proposal to take drugs for cardiovascular diseases, epilepsy or depression.

No standard exists so far to measure treatment outcome in VM. In vestibular disease, most tools have been developed in vestibular rehabilitation for non-episodic conditions, like vestibular neuritis [20]. In episodic disorders, usually attack frequency and intensity have been used but also global measures of the physical and emotional impact like the Dizziness Handicap Inventory [21].

After a diagnosis of VM has been established, the issue of the need for a treatment needs to be addressed with the patient. Vertigo is nearly always a worrying symptom but not always debilitating enough to warrant treatment. It is obviously important to establish at least approximately attack frequency, duration and severity as the need for treatment will depend on these factors. Some patients are reassured to know what they have, and if attacks are rare/mild/short, they might just decide to get on without treatment.

But what is considered as rare, mild or short, and what is the degree of suffering and the impact on their lives will vary from patient to patient, such that it is important to take into consideration patient preferences and needs.

Need for treatment will often be present as studies have shown that VM patients are often more handicapped than other vestibular patients [22, 23]. On top of this VM is the vestibular disorder leading most often to complications like chronification [10, 24], anxiety and avoidance behaviour. It is therefore important to try to control VM in order to be able to address better these complications.

Another aspect is that the “activity” of VM varies naturally over time, just like migraine, and the needs for treatment, in particular the daily administration of prophylactic drugs, are usually limited in time.

Most studies so far have been uncontrolled; only recently few controlled interventions for drugs and physical therapy have been published.

Triptans are a class of drugs developed to treat acute migraine headache. In a retrospective study based on patient records, sumatriptan was found to work independently if the vestibular symptom was or was not with accompanied by headache [27].

In a placebo-controlled study with zolmitriptan as primary outcome measure a clear relief of symptoms after 2 h was successful in 38 % for zolmitriptan versus 22 % for placebo [28] in ten patients with altogether 17 attacks, which was inconclusive.

So far it is not established if the vestibular symptoms in VM arise from migraine aura mechanisms. It is however interesting to look what the experiences were, when specifically targeting the treatment of migraine auras.

Sumatriptan 6 mg administered subcutaneously was found ineffective to shorten visual auras and was ineffective in preventing headache if taken during the aura [29]. A small study found that rizatriptan does not consistently reduce visually induced motion sickness in migraineurs but might have diminished motion sickness potentiation by cranial pain [30].

Ergots are not recommended for the treatment of migraine preceded by major aura because of potential vasoconstriction [31] and are contraindicated for hemiplegic and migraine with brain stem aura [32]. It is therefore reasonable not to try them in attacks of vestibular migraine.

Non-steroidal anti-inflammatory drugs have so far only been reported in one study [27] to be useful to treat vertigo attacks but were ineffective for migraine aura [31].

Altogether it seems that drugs effective in treating migraine headache (triptans, NSAID) do not work so well for vertigo or might be hazardous to use (ergots). If a treatment of attacks is needed, it is safer to use a generic strategy to relieve vertigo and nausea as in other causes of acute vertigo.