What is a Vestibular Migraine?

Experiencing migraine symptoms along with vertigo

Getty Images/Martin Rogers.

Imagine a trip to a lovely theme park or carnival, filled with friends, cotton candy, and some warm sunshine. Sounds pleasant until you go on the tilt-a-whirl ride and experience debilitating dizziness. This may be how it feels for some of you who suffer from vestibular migraines, a type of headache that causes episodic dizziness, usually without a headache, in people who have a history of migraines.

Introduction

Vestibular migraines affect up to 1% of the population. The vertigo patients with vestibular migraine experience is different from the vertigo one may experience during a migraine aura, in that the vertigo typically does not last 5-60 minutes like an aura and does not usually precede the head pain. Recently, the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS) created criteria that doctors can use to diagnose vestibular migraines.

Classification Criteria

According to the classification criteria of the second edition of the International Classification of Headache Disorder (ICHD-II), symptoms of vestibular migraine include:

  • A current or past history of migraine with or without aura
  • At least 5 episodes of vestibular symptoms with moderate to severe intensity lasting from 5 minutes to 72 hours
  • At least 50 percent of the episodes have one or more of these characteristics
    • visual aura
    • photophobia and phonophobia
    • headache with at least two the following features: one-sided head pain, pulsating, moderate or severe intensity, aggravation by routine physical activity
  • Symptoms are not explained by another medical condition

    What are Vestibular Symptoms?

    Vestibular symptoms, according to the Bárány Society's Classification of Vestibular Symptoms include:

    • spontaneous vertigo (when a person feels themselves moving or that their surroundings are spinning or flowing)
    • positional vertigo (vertigo induced by a change in head position)
    • visually-induced vertigo (vertigo induced by a large, moving visual stimulus)
    • head motion-induced vertigo or dizziness with nausea

    Vestibular symptoms are "moderate" if they interfere with daily activities and "severe" if they prohibit daily activities.

    Diagnosis

    The diagnosis of vestibular migraine is made by a neurologist or headache specialist. There are no special tests, but rather the diagnosis is a clinical one, meaning that it is made by a patient describing her symptoms to the doctor. Nevertheless, your doctor will probably have you undergo imaging of the brain with a magnetic resonance imaging (MRI) and/or magnetic resonance angiography (MRA) to ensure that no other serious medical condition is going on such as: a stroke or vertebrobasilar transient ischemic attack (TIA).

    You may also undergo audiometry or a hearing test to rule out Meniere's disease. Other medical conditions that can be similar to vestibular migraine are anxiety-related dizziness or panic attacks, benign paroxysmal positional vertigo, or another type of migraine called a basilar migraine.

    Treatment

    Treatment of vestibular migraine is similar to the treatment of migraines in that both acute and preventive treatments are considered, in addition to trigger avoidance Ergotamine or triptans are reasonable options for acute treatment, analogous to their use in episodic migraine. If a person's vestibular migraines are occurring frequently and/or particularly disabling, than a preventive medication like a beta blocker or calcium channel antagonist, like verapamil, might be useful. Sometimes, vestibular suppressants, which could be defined as "anti-vertigo" medications, have been used. Examples of vestibular suppressants include: antiemetics like promethazine, benzodiazepines like lorazepam, or antihistamines like meclizine. Vestibular rehabilitation is also something that should be considered in patients with vestibular migraine. In this type of physical therapy, patients learn how to improve their sense of balance and decrease their sensation of dizziness, when a vestibular migraine is occurring.

    Bottom Line

    If you suffer from episodic vertigo with or without a headache, than review your symptoms with your healthcare provider. Your doctor will rule out other causes of dizziness before making the diagnosis of vestibular migraine. But, if this is the diagnosis, you are not alone, and there are lots of treatment options out there.

    Sources:
    Bisdorff AR. Management of vestibular migraine.Ther Adv Neurol Disord.2011 May; 4(3): 183-191.
    Black DF & Robertson CE. Vestibular migraine. In: UpToDate, Basow DS (Ed), UpToDate, Waltham, MA, 2013.
    Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders: 3rd Edition (beta version)". Cephalalgia 2013;33(9):629-808.
    Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-72.

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