Vestibular migraine is the most common neurological cause of vertigo in adults. It affects approximately 3% of the population, and results in significant loss of productivity and healthcare resource utilization among adults. Unfortunately, it is often mis- and under-diagnosed, leading to delays in the appropriate treatment and care.

Vestibular migraine can be understood as episodic attacks of vestibular symptoms causally related to migraine. It is important to note that dizziness and vertigo are common in people who have migraine, and not everyone with migraine and vestibular symptoms have vestibular migraine.

Diagnosis

According to the International Classification of Headache Disorders (3rd edition), the diagnosis of vestibular migraine can be made if the following criteria are met:

  • A. At least 5 episodes that meet criteria C and D.
  • B. A current or previous history of migraine (with or without aura)
  • C. Vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hours
  • D. At least half of the episodes must be associated with at least one migraine feature:
    • Headache – must have at least two of the following:
      • Unilateral (one-sided)
      • Throbbing
      • Moderate to severe intensity
      • Aggravated by routine physical activity
    • Photophobia (light sensitivity) & phonophobia (sound sensitivity)
    • Visual aura

Many different types of vestibular symptoms may occur during vestibular migraine attacks. These can be broadly classified into spontaneous and triggered vertigo. Spontaneous vertigo refers to vertigo that occurs without any precipitating events, and can be experienced in many ways including spinning, tumbling, falling, shimmering, floating, tilting, swaying, rocking and bobbing. Triggered vertigo refers to vertigo that is related to a specific provoking factor; for example, head motion-induced vertigo is vertigo that occurs during head movements, and visually-induced vertigo refers to vertigo triggered by busy visual scenes.

Headaches may or may not occur during vestibular migraine attacks, and are not required for the diagnosis to be made. Yes, migraine is more than just a headache – you do not need to have a headache to be diagnosed with migraine. In the absence of headaches with the attacks of vestibular symptoms, the occurence of photophobia & phonophobia, or visual aura can be sufficient to make the diagnosis of vestibular migraine.

Other symptoms may also occur during vestibular migraine attacks, including brain fog, hearing changes, head pressure, ear fullness or pressure, tinnitus (ringing in the ears), tingling sensations, blurry vision. It is important that you be evaluated by a neurologist to exclude other disorders that can cause these symptoms. The presence of ear fullness, tinnitus, and muffled hearing can often cause confusion with Ménière’s disease.

Triggers

Vestibular migraine triggers are essentially similar to migraine triggers. Common triggers include:

  • Stress
  • Lack of sleep
  • Dehydration
  • Skipping meals
  • Weather changes
  • Hormonal changes
  • Bright lights
  • Physical exhaustion
  • Seasonal allergies

Food Triggers

Migraine food triggers are numerous, and can be unique to the individual. Some of the common food triggers include:

  • Caffeine
  • Chocolate
  • Monosodium glutamate (MSG)
  • Red wine
  • Aged cheeses
  • Smoked meats
  • Cured meats
  • Fermented foods

Treatment

Treatment for vestibular migraine can be divided into several categories:

Lifestyle ModificationTrigger Avoidance
Exercise
Regular Sleep
Regular Meals
Stress Management
Acute (Rescue) TreatmentMedications used for rescue include:
– Acetaminophen
– Non-steroidal Anti-Inflammatory Drugs
– Triptans
– Benzodiazepines
– Anti-emetic medications
Preventive TreatmentVitamins & Supplements
Prescription Medications:
– Beta blockers
– Antiepileptic medications
– Tricyclic Antidepressants
– Calcium channel blockers
– Newer antidepressants (SSRI/SNRI)
– Botulinumtoxin injections
Neuromodulatory Devices

The choice of treatment(s) should be discussed with your neurologist to ensure that you have the most effective and safest therapies.