Ian Purcell MD PhD Monali Patel MD Otoneurology Call 858 223 2172
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Vestibular Migraine

Vestibular migraine is a common cause of recurrent vertigo, in which migraine affects the balance system, with or without a headache.

At a glance

Symptoms
Vertigo lasting minutes to days, motion sensitivity, often with migraine features
Common causes
Migraine mechanisms acting on the balance system
How it's diagnosed
A history that meets diagnostic criteria, with testing to exclude other causes
Treatment
Trigger control, preventive medication or supplements, and rehabilitation

Overview

Vestibular Migraine (VM), characterized by episodic vertigo tied to migraine conditions, represents a significant intersection between the neurological and vestibular systems. Varied terminology like migraine-associated vertigo and benign recurrent vertigo, among others, reflects the diverse presentations and commonalities with conditions such as "Vestibular Meniere's disease." The underlying mechanisms connecting migraine and vertigo remain complex and not fully elucidated, encompassing theories from aura phenomena to labyrinthine disturbances.

Diagnosis

Diagnosing VM involves a clinical approach, distinguishing between definite and probable VM through criteria developed by Neuhauser et al. This diagnosis hinges on:

  • Episodic vestibular symptoms of moderate to severe intensity
  • A history or concurrent diagnosis of migraine
  • Presence of migrainous features during vertigo episodes
  • Exclusion of other causes through comprehensive evaluation

Clinical practice emphasizes the importance of observing patients during acute episodes and utilizing diagnostic aids like infrared video oculography and serial hearing assessments to accurately pinpoint the nature of vertigo attacks.

Treatment

VM treatment mirrors that of classic migraines, aiming to alleviate vertigo symptoms and prevent future episodes. Initial strategies often include lifestyle and dietary modifications, such as a low tyramine diet and hydration emphasis. Pharmacological interventions typically begin with migraine abortive medications, with preventive medications considered based on attack frequency and severity. Options include:

  • Topamax, particularly for individuals seeking weight management
  • Namenda for broad tolerability
  • Amitriptyline or nortriptyline when depression is present
  • Propranolol for concurrent hypertension
  • Verapamil, though with varied efficacy

The choice of preventive medication also considers comorbid conditions, tailoring treatment to the individual's broader health profile.

Vestibular Migraine: Epidemiology and Distinction

The prevalence of VM exceeds that of Ménière’s disease, underlining its significance in the dizziness clinic patient population. Distinguishing VM from Ménière’s and other vertigo causes is crucial for targeted management. Interestingly, studies suggest a pathophysiological link between Ménière’s disease and migraine, pointing to shared migrainous symptoms during attacks.

In our clinical approach, the nuanced relationship between Ménière’s disease and migraine informs treatment, adopting migraine prophylactic and abortive strategies alongside specific interventions for Ménière’s where applicable. This comprehensive method underscores the importance of personalized care in managing vestibular and migraine disorders.

Testing that can help

Testing is chosen from your history and examination. These are the tests most often used here.

DizzyDoctor Vertigo Recording GogglesHigh-resolution infrared video goggles used to document eye movements during dizziness and positional vertigo evaluation.Videonystagmography (VNG)A comprehensive eye-movement test battery used to evaluate vestibular and oculomotor function.TRV ChairA mechanical repositioning chair used to evaluate and treat complex positional vertigo.Computerized Dynamic Posturography (CDP)Balance platform testing that measures how vision, vestibular input, and body sensation contribute to postural control.
Specialty care: Vestibular DisordersVestibular disorders encompass a range of conditions affecting the vestibular system, which is crucial for maintaining balance and spatial orientation.Migraine VariantMigraine can cause much more than headache, including episodes of vertigo, visual disturbances, and fluctuating hearing or tinnitus, sometimes with little or no head pain.Meniere's DiseaseMeniere's disease is an inner ear disorder that causes attacks of vertigo along with fluctuating hearing loss, tinnitus, and a feeling of fullness in the ear.Migraine cocktailThe migraine cocktail is a daily regimen of vitamins and supplements used to help reduce how often migraines happen and how severe they are.

When to seek urgent care

Call 911 or go to the nearest emergency department if dizziness or imbalance starts suddenly together with any of the following, since these can be signs of a stroke or another emergency:

  • Weakness or numbness of the face, arm, or leg, especially on one side
  • Trouble speaking or understanding speech
  • Double vision or sudden loss of vision
  • A sudden, severe headache
  • Inability to walk or stand
  • Chest pain, fainting, or a seizure

Further reading

This article is for general education and does not replace a medical evaluation. Testing and treatment are chosen for each patient after a full history and examination.