Vestibular Migraine

What vestibular migraine feels like

During an attack, people may experience:

• spontaneous vertigo: a sensation of spinning or the room moving
• positional vertigo: triggered by changing head position
• visually induced dizziness: triggered by moving scenes, scrolling, busy patterns or supermarkets
• head-motion dizziness: worse with turning the head
• imbalance and unsteadiness
• nausea and vomiting
• sensitivity to light (photophobia) and sound (phonophobia)
• visual aura
• ear fullness or mild tinnitus in some
• a headache before, during or after vertigo, or none at all

Between attacks, many people feel normal, though some have ongoing motion sensitivity.

Diagnostic criteria

The ICHD-3 and Bárány Society criteria for vestibular migraine require:

1. at least 5 episodes of moderate or severe vestibular symptoms lasting 5 minutes to 72 hours
2. a current or past history of migraine with or without aura
3. at least half of the episodes with one or more migraine features: migraine-type headache, light and sound sensitivity, or visual aura
4. no better explanation by another condition

Causes and triggers

The exact mechanism is not fully understood. Migraine involves abnormal processing in brain networks that also handle balance and spatial orientation, explaining vertigo.

Common triggers:

• lack of sleep or irregular sleep
• stress and the let-down after stress
• skipped meals and dehydration
• hormonal changes, especially around periods and perimenopause
• certain foods: aged cheese, chocolate, red wine, MSG, processed meats (vary by person)
• caffeine excess or withdrawal
• bright or flickering lights, busy visual environments
• weather and barometric changes
• motion: cars, boats, flights

Vestibular migraine vs other causes of vertigo

Vestibular migraine and Ménière's disease can coexist. See also migraine-associated vertigo.

Diagnosis

There is no specific test. A doctor, often a neurologist or ENT specialist, will:

• take a detailed history of attacks, triggers and headaches
• perform a neurological and ear examination, including positional tests for BPPV
• order a hearing test (audiogram) to look for Ménière's
• sometimes order vestibular function tests
• order an MRI if there are unusual features or stroke concerns

Treatment

Lifestyle and triggers

• regular sleep, meals and hydration
• limit caffeine and alcohol
• manage stress: exercise, relaxation, CBT
• keep a diary to identify personal triggers
• regular aerobic exercise

Acute treatment

• lie still in a quiet, dark room
• anti-nausea medicines (such as meclizine, promethazine or ondansetron)
• migraine medicines such as triptans may help some people, especially when headache is present
• NSAIDs for headache, following the label dose

Preventive treatment

For frequent or disabling attacks, daily migraine preventives may be used:

• beta-blockers (propranolol)
• tricyclic antidepressants (amitriptyline, nortriptyline)
• venlafaxine
• topiramate
• calcium channel blockers (verapamil; flunarizine outside the US)
• CGRP-targeting medicines, used for migraine, are being studied for vestibular migraine

It may take 2 to 3 months to judge whether a preventive is working.

Vestibular rehabilitation therapy

Exercises guided by a physical therapist retrain the balance system and reduce motion sensitivity and ongoing dizziness between attacks.

Outlook

Vestibular migraine is a long-term condition, but most people achieve a significant reduction in attacks with trigger control, medicines and rehabilitation. Symptoms often fluctuate with life stages such as perimenopause.

Frequently asked questions

What are the symptoms of vestibular migraine?

The main symptoms are episodes of vertigo or dizziness lasting minutes to days, often with nausea, sensitivity to light, sound and motion, and unsteadiness. A headache may occur with some attacks, but many attacks happen without any headache.

Can you have vestibular migraine without a headache?

Yes. Many people with vestibular migraine have vertigo attacks with no headache, especially later in life. Diagnosis relies on a history of migraine and other migraine features such as light or sound sensitivity during attacks.

How is vestibular migraine diagnosed?

There is no single test. Doctors diagnose it from the pattern of symptoms, a history of migraine and the presence of migraine features during attacks, after ruling out other causes like Ménière's disease, BPPV and stroke with examinations, hearing tests and sometimes MRI.

What triggers vestibular migraine?

Common triggers include lack of sleep, stress, skipped meals, dehydration, hormonal changes, certain foods and drinks, bright or flickering lights, busy visual environments and motion. Triggers vary between people, so a diary can help.

How is vestibular migraine treated?

Treatment combines avoiding triggers, medicines for nausea and migraine during attacks, daily preventive medicines for frequent attacks, and vestibular rehabilitation exercises. Most people see a substantial improvement.