Neuro(b)log for Patients

What is vestibular migraine

Vestibular migraine (sometimes called migrainous vertigo) is a type of migraine in which the main symptoms are not always headache but dizziness, a spinning sensation or balance disturbance, often occurring without head pain. Nearly one third of patients report isolated vertigo outside of headache attacks. It often goes unrecognized because patients may not meet the usual diagnostic criteria for migraine. Interest in vestibular migraine has grown over the past decade; it affects approximately 1–3% of the population. Up to 95% of patients with vestibular migraine could benefit from migraine treatment and experience improved quality of life even if they do not have typical migraine headaches. It is estimated that up to 60% of patients with chronic migraine and nearly 73% of those with migraine with aura may have vestibular migraine.

Symptoms

• Dizziness lasting seconds to days: sudden sensations of spinning, rocking, swaying or the feeling that the environment is moving (swaying, rocking, sliding, rotation clockwise or counterclockwise).

• Triggers: movement, changes in head position, rapid eye movements or bright light.

• Other sensations: lightheadedness, a floating sensation, visual disturbances (visual aura, "visual snow" resembling TV static, oscillopsia — the perception that stationary objects are moving).

• Headache: may be absent; some patients report only pressure in the head or neck (occipital area).

• Associated problems: nausea, sensitivity to light or sound, anxiety or reduced independence.

Why it happens briefly and clearly

Patients with vestibular migraine often also experience motion sickness (nausea and vertigo in vehicles) and frequently have a family history of migraine. The exact cause is not fully understood. Both pain pathways and pathways carrying vestibular and visual information appear to be involved. Common triggers include stress, sleep changes, certain foods, hormonal fluctuations and intense light or noise.

Hormonal changes (for example during perimenopause) or alterations in brain circuits can cause dizziness to replace typical headache. In women with migraine, perimenopausal changes may lead to disappearance of headache attacks that are replaced by balance symptoms. This is linked to hormonal effects and receptor expression in brain regions such as the brainstem, cerebellum and hypothalamus, and to trigeminal nerve pathways. Patients with vestibular migraine show higher rates of depression, anxiety and reduced independence. Functional imaging demonstrates changes in brainstem nuclei involved in balance regulation and in pain pathways.

In some people neuropeptides such as CGRP (calcitonin gene‑related peptide) and altered connections between the cerebellum, thalamus and vestibular system play a role. CGRP is produced in central and peripheral nervous system cells, including trigeminal ganglia and dorsal root ganglia; it promotes inflammation and vasodilation in the meninges, which can amplify pain and sensitivity during migraine. Elevated CGRP levels have been found during migraine attacks and in chronic migraine, which is why treatments effective for migraine with aura and certain nutraceuticals (e.g., magnesium, riboflavin, coenzyme Q10) may also help vestibular migraine.

How it is diagnosed

Otoneurological examination is a specialized assessment for balance disorders, dizziness and related ear and neural functions; it combines ENT and neurological methods and includes history, clinical vestibular tests and instrumental studies (audiology, electronystagmography ENG). Patients with vestibular migraine often show no abnormalities on oto‑neurological testing, but the exam is important to exclude other causes of vertigo such as benign paroxysmal positional vertigo (BPPV), Menière's disease, vestibular neuritis and other conditions. Migraine sufferers have a higher likelihood of BPPV, Menière's disease, motion sickness, tinnitus and hearing loss. Referral to an ENT specialist in oto‑neurology is important because some hearing‑related symptoms overlap with Menière's disease.

Neurological assessment includes clinical neurological examination and instrumental tests such as brainstem auditory evoked potentials (BAEP), visual evoked potentials (VEP), EEG and brain imaging (MRI).

Treatment

Management includes acute pharmacological treatment for attacks and preventive therapy, with vestibular rehabilitation as an integral component. Treatment is individualized and may combine migraine medications, vestibular physiotherapy and lifestyle measures to avoid triggers.

Conclusion

Vestibular migraine is a neurological disorder causing recurrent episodes of dizziness or other balance disturbances often associated with migraine features. Diagnosis and management belong to specialists — ENT physicians and neurologists. If you experience severe or recurrent attacks, consult your primary care doctor or a specialist.

You may also contact my clinic, where we have the equipment to perform EEG, BAEP and VEP testing in one place.

I will close with a quote: "Migraine … is not an enemy to be got rid of as quickly as possible. It is, on the contrary, a vital message from the organism that must be listened to, understood and responded to appropriately." — Oliver Sacks.

MUDr. Petra Mištríková, MBA

References for further study:

Villar-Martinez MD, Goadsby PJ. Vestibular migraine: an update. Curr Opin Neurol. 2024 Jun 1;37(3):252-263. doi: 10.1097/WCO.0000000000001257. Epub 2024 Apr 15. PMID: 38619053; PMCID: PMC11064914.

Smyth D, Britton Z, Murdin L, Arshad Q, Kaski D. Vestibular migraine treatment: a comprehensive practical review. Brain. 2022 Nov 21;145(11):3741-3754. doi: 10.1093/brain/awac264. PMID: 35859353; PMCID: PMC9679161.

Benjamin T, Gillard D, Abouzari M, Djalilian HR, Sharon JD. Vestibular and auditory manifestations of migraine. Curr Opin Neurol. 2022 Feb 1;35(1):84-89. doi: 10.1097/WCO.0000000000001024. PMID: 34864754; PMCID: PMC8755616.

Hac NEF, Gold DR. Advances in diagnosis and treatment of vestibular migraine and the vestibular disorders it mimics. Neurotherapeutics. 2024 Jul;21(4):e00381. doi: 10.1016/j.neurot.2024.e00381. Epub 2024 Jun 5. PMID: 38845250; PMCID: PMC11284549.

Zhang L, Chen QH, Lin JH, Zhou C, Pan YH. Research on the Relationship Between Vestibular Migraine With/Without Cognitive Impairment and Brainstem Auditory Evoked Potential. Front Neurol. 2020 Mar 20;11:159. doi: 10.3389/fneur.2020.00159. PMID: 32265817; PMCID: PMC7099046.