Vestibular Migraine

Vestibular migraine (VM) is a headache disorder in which typical migraine headaches occur with dizziness, vertigo and/or imbalance.

Other names for VM include migrainous vertigo, migraine-related vestibulopathy, and migraine-related dizziness.

Vestibular Migraine Q&A With Christina Sun-Edelstein, MD

“I have had migraines since my teens.  The headaches are pretty severe, and I always vomit during them.  For a long time these headaches occurred only every few months, and if I went to sleep in a dark, quiet room, I’d feel much better after a few hours.  Lately I’ve noticed that I also get really dizzy and unsteady during my migraines.  If I don’t hold onto the wall while trying to get to my bedroom to lie down, I’ll just fall over.  Sleep still helps for the headache, but when I wake up I still feel unsteady, like I’m walking around on a soft mattress.  This feeling can last for the whole day, and even part of the next day.  In between my migraines I’ve had a few other similar episodes of dizziness and unsteadiness.  These can happen at any time, especially if I move my head quickly.”

If dizziness and imbalance are a major part of your migraine attacks, you may be suffering from vestibular migraine.

What is vestibular migraine?

Vestibular migraine (VM) is a headache disorder in which typical migraine headaches occur with dizziness, vertigo and/or imbalance.

Other names for VM include migrainous vertigo, migraine-related vestibulopathy, and migraine-related dizziness.

Who gets vestibular migraine?

People who have had migraines for many years may develop VM.  It seems to occur more often in women than men.  While people with standard migraine have a tendency to have motion sickness, those with VM are even more likely to suffer from motion sickness.

What are the characteristics of vestibular migraine?

Episodes of dizziness can be as short as a few seconds or as long as a whole day.  The dizziness may feel like a sense of unsteadiness or imbalance.  People who experience vertigo with VM may feel like their surroundings are moving (i.e.  “the room is spinning”), or have the sensation that they are moving when they are not.  Often people with VM veer to one side when trying to walk during episodes.  Though some attacks of dizziness occur with typical migraine headaches, people with VM may also experience headaches without dizziness, or dizziness without headaches.

Episodes of dizziness can be triggered by rapid head movements, or looking at flickering lights or busy patterns such as checkerboards.  Other typical triggers include riding on an escalator, or looking for items on supermarket shelves.

Why does dizziness and imbalance occur in some, but not all, people with migraines?

The mechanism of VM is not well-understood.  During attacks of VM there may be interactions between pain and balance pathways in the brain that do not occur during typical migraine attacks.   Also, there may be some abnormalities in the inner ear of VM sufferers, causing balance problems.

Are there any other symptoms or disorders that are associated with vestibular migraine?

There is an association between anxiety and VM.  As previously mentioned many people with VM also suffer from motion sickness.  There may also be a connection between VM and Meniere’s Disease, which is a disorder of the inner ear characterized by dizziness, tinnitus (ringing in the ears), hearing loss, and a sensation of fullness or pressure in the ear.

How is vestibular migraine treated?

The medications that are used to treat VM are similar to those that are used for standard migraine headaches.  Acute medications such as triptans and anti-inflammatories can be helpful for treating individual attacks, and daily preventative medications can be used to decrease the frequency of attacks.  Physiotherapy may also be particularly helpful in the treatment of VM.  Some people with VM find that it improves spontaneously over time, without any treatment.

Vestibular Migraine Overview

Medically reviewed by Dr. John Waterston on 28 June 2019.

vestibular migraine

Migraine attacks may be accompanied by neurological symptoms such as visual disturbance, focal sensory change, speech disturbance and weakness. These neurological symptoms classically occur as an “aura” prior to the headache (known as migraine with aura) but not all patients with migraine experience an aura (known as migraine without aura).

Vestibular symptoms such as dizziness, vertigo, and balance disturbance can also occur in the setting of migraine but, in contrast to the normal aura, these neurological symptoms can occur before, after and during the headache, as well as in the headache free period. The exact mechanism of the vestibular symptoms in migraine remains unknown. Vestibular migraine has been included as a diagnostic category in the latest International Classification of Headache Disorders criteria (see below), and is felt to be the second most common vestibular syndrome.

Hearing related symptoms such as distortion and hearing loss are less common in vestibular migraine compared to other inner ear conditions such as Ménière’s disease, though they can occur rarely. In contrast tinnitus and phonophobia occur quite commonly in vestibular migraine.

Some patients with a history of typical migraine attacks at a younger age can note a change in the character of their attacks many years later, with neurological symptoms including vertigo becoming more prominent, and even occurring without any associated headache.

The nature of the dizziness and vertigo in this condition can be quite varied. It can consist of severe, spontaneous episodes of spinning vertigo and vomiting lasting several hours. Motion-induced dizziness and vertigo, as well as balance dysfunction can also be prominent symptoms. Patients with migraine are more prone to motion sickness and are also more sensitive to certain visual stimuli such as brightly patterned floors and large crowded shopping centres.

The same factors that are responsible for precipitating migraine headaches can also trigger the vestibular symptoms. These triggers include stress, lack of sleep, oversleep, diet and hormonal factors in women such as the oral contraceptive pill, hormone replacement therapy and the menopause. Many patients however are not aware of any obvious triggers.

Treatment includes modification of potential triggers. Drug therapy includes the treatment of acute attacks with anti-nausea drugs. These drugs should not be taken on a regular basis for long periods due to the risk of neurological side-effects. Migraine prophylaxis used for headache prevention is also frequently effective treatment for the vestibular symptoms. These medications include pizotifen (Sandomigran), propanolol (Inderal), verapamil (Isoptin), topiramate (Topamax) and valproate (Epilim).

If there is predominantly motion-induced dizziness, exercise therapy prescribed by a physiotherapist may be used to reduce these symptoms.

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International Classification of Headache Disorders (ICHD3) criteria for Vestibular migraine

  • a) At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours.
  • b) Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD).
  • c) One or more migraine features with at least 50% of the vestibular episodes.
    • headache with at least two of the following characteristics: one sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity
    • photophobia and phonophobia,
    • visual aura.
  • d) Not better accounted for by another vestibular disorder
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