Vestibular Migraine

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.

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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