What Are the Symptoms of Vestibular Migraine
Vestibular migraine produces a combination of vestibular (balance and spatial orientation) symptoms and migraine-associated features. Head pain may be absent in up to 30% of vestibular migraine attacks, making vestibular migraine particularly difficult to recognize.
Vestibular Symptoms
- Spontaneous vertigo, a sensation of spinning, rocking, or tilting without any external movement
- Positional vertigo, triggered by changes in head position
- Dizziness or a persistent sensation of unsteadiness
- Difficulty walking or maintaining balance during an attack
- Episodes lasting anywhere from a few minutes to 72 hours
Migraine-Associated Symptoms
- Photophobia (sensitivity to light) and phonophobia (sensitivity to sound) during vestibular episodes
- Sensitivity to motion or visual stimulation such as scrolling screens or busy environments
- Nausea and vomiting
- Moderate to severe head pain accompanying some but not all vestibular episodes
- Tinnitus (ringing in the ears) and a feeling of ear fullness in some cases
Between Attack Symptoms
- Persistent mild dizziness or unsteadiness between episodes in some individuals
- Heightened sensitivity to motion such as car travel, escalators, or busy visual environments
- Anxiety related to the unpredictability of vertigo episodes, which is common and can significantly worsen overall quality of life
What Are the Causes of Vestibular Migraine?
Neurological Causes
- Trigeminal nerve activation: Activation of the trigeminal nerve (the main pain pathway in migraines) spreads inflammatory signals to the vestibular nucleus (the brain region responsible for balance and spatial orientation), disrupting normal vestibular function and triggering vertigo
- Cortical spreading depression: The wave of electrical suppression that causes migraine aura can spread into vestibular processing regions of the brain, producing vestibular symptoms
- Serotonin dysregulation: Serotonin plays a key role in both migraine generation and vestibular function. Fluctuations in serotonin levels during a migraine event disrupt vestibular signaling, contributing to dizziness and vertigo
- CGRP overexpression: Elevated CGRP (calcitonin gene-related peptide) levels during migraine attacks affect blood flow and neurological signaling in the inner ear and brainstem vestibular pathways
Genetic Factors
* Vestibular migraines have a strong genetic link and are more common in first-degree relatives of patients with vestibular migraines
* Genetic factors that are common to both vestibular migraines and migraines with aura point to similar neurological pathways in both conditions
Common Triggers
- Stress and emotional upheaval
- Sleep deprivation or irregular sleep patterns
- Hormonal fluctuations, particularly around menstruation
- Dietary triggers including aged cheeses, red wine, caffeine withdrawal, and MSG (monosodium glutamate)
- Bright or flickering lights and visually stimulating environments
- Weather changes, particularly barometric pressure drops
How Is Vestibular Migraine Diagnosed?
Vestibular migraine can be clinically diagnosed based on the history of symptoms and the absence of other vestibular and neurological disorders.
Diagnostic Criteria
For the diagnosis of vestibular migraine, the following criteria have to be satisfied according to the Barany Society and International Headache Society joint criteria (2022):
- At least five episodes of vestibular symptoms of moderate to severe intensity lasting between 5 minutes to 72 hours
- Presence of a history of migraine with or without aura in the past or currently
- Presence of two or more of the following features of migraine in at least 50% of episodes of vestibular symptoms:
- Head pain
- Photophobia
- Phonophobia
- Visual aura
- Symptoms not explained by another vestibular or neurological disorder
Investigations to Rule Out Other Conditions
- MRI of the brain and inner ear
- To rule out other causes of vertigo
- To rule out acoustic neuroma, a benign tumor affecting the nerve carrying sound
- To rule out multiple sclerosis
- Audiometry
- Hearing test to distinguish between vestibular migraine and Meniere’s disease, characterized by hearing loss
- Videonystagmography
- Eye movement test to check for abnormalities in the vestibular system
- Blood tests: To rule out autoimmune or metabolic causes of vestibular symptoms
Vestibular Migraine vs Meniere's Disease
How Is Vestibular Migraine Treated?
Acute Treatment During an Attack
- Rest in a quiet, dark environment and minimize head movement during acute vertigo episodes
- Stay hydrated and avoid skipping meals to prevent compounding triggers during an attack
- Take prescribed acute medications at the earliest onset of vestibular symptoms for the best response
- Avoid driving or operating machinery during vestibular episodes due to balance impairment
Acute Medications
- Triptans such as rizatriptan and zolmitriptan are effective for vestibular migraine attacks accompanied by head pain
- Vestibular suppressants such as promethazine or diazepam may be used for short-term relief of severe vertigo during acute attacks
- Antiemetics such as ondansetron relieve nausea and vomiting during acute vestibular episodes
Preventive Treatment
Preventive treatment is recommended when vestibular migraine episodes occur more than twice per month or significantly impact daily functioning.
- Beta-blockers such as propranolol and metoprolol reduce overall migraine and vestibular episode frequency
- Tricyclic antidepressants such as amitriptyline address both migraine and vestibular symptoms through serotonin modulation
- Calcium channel blockers such as verapamil and flunarizine reduce vestibular migraine frequency, particularly in individuals who do not tolerate beta-blockers
- CGRP inhibitors such as erenumab are being increasingly used for vestibular migraine prevention with promising results in emerging clinical evidence
Vestibular Rehabilitation Therapy
Vestibular rehabilitation therapy (VRT) is a physiotherapy program that helps the brain to adapt to vestibular disorders.
* VRT includes specific exercises that improve balance, eye movements, and responses to motion
* VRT is particularly beneficial for people who experience dizziness or unsteadiness in-between attacks
* A study published in the Journal of Vestibular Research (2021) demonstrated that VRT with preventive medication for migraines resulted in more significant improvements in balance and quality of life when compared to using the medication as a standalone treatment
Lifestyle Modifications
- Maintain a consistent sleep schedule to stabilize the migraine and vestibular threshold
- Identify and avoid personal dietary and environmental triggers using a migraine and symptom diary
- Manage stress through cognitive behavioral therapy (CBT), mindfulness, or regular moderate exercise
- Limit caffeine intake and avoid sudden caffeine withdrawal, which is a recognized vestibular migraine trigger
When Should You See a Doctor?
Seek immediate medical attention if:
- Vertigo occurs suddenly and severely for the first time
- Vertigo is accompanied by sudden hearing loss, double vision, difficulty swallowing, or facial numbness
- One-sided weakness or speech difficulty accompanies dizziness
- Symptoms do not resolve within 72 hours
Seek non-emergency neurological or ENT evaluation if:
- Recurrent vertigo episodes are occurring without a confirmed diagnosis
- Vestibular symptoms are significantly affecting work, driving, or daily activities
- Current treatments are not adequately controlling episode frequency or severity
Conclusion
Vestibular migraines are the most common cause of spontaneous episodic vertigo in adults and are often mistaken for Meniere's disease and BPPV. Vestibular migraines are caused by activation of the trigeminal nerve, cortical spreading depressions, and serotonin dysregulation in the brain's vestibular processing areas. Vestibular migraines can be treated with an accurate diagnosis, management of trigger factors, and a list of medications and vestibular rehabilitation therapy. Anyone with recurrent episodes of vertigo should consult a neurologist or ENT specialist with knowledge of vestibular migraines.
