Vestibular Migraine - Symptoms, Treatments, and Related Disorders

Vestibular Migraines vs Other Causes of Dizziness and Vertigo

A woman with a migraine headache and dizziness holding her head
What are vestibular migraines, what are the symptoms, and how are they treated?. Getty Images

If you've been told that you have vestibular migraines, or suspect you may have this disorder, you're probably feeling very anxious. What exactly are these migraines, how are they diagnosed, and how are they treated? How do you know that it's not something else, such as a stroke? What can you expect and what is the prognosis?

Vestibular migraines are thought to be more common than previously thought, affecting up to one percent of the population.

Vestibular Migraines - Definition

The term "vestibular migraine" refers to dizziness that results from migraine phenomena. The vestibular system is that part of the inner ear which tells us where we are in space in three dimensions. If you've even spun in circles rapidly and then stopped, you know what happens when your vestibular system isn't working properly.

Also called migraine associated with vertigo (MAV), or migrainous vertigo, vestibular migraines are one of the most common causes of sudden vertigo. Vertigo, in turn, is defined as the sensation of dizziness which is associated with the feeling that you are spinning or the world is spinning around you.

Migraine Headaches and Dizziness

Migraines are one of the most common neurological disorders. When most people think of migraines, they imagine terrible headaches, usually worsened by light or bright noise. In some cases of migraine, unusual patterns may appear in front of the migraneur's eyes, or they may get unusual sensations of numbness or tingling.

(during the migraine or as an aura before a migraine.) Migraines can cause many other kinds of neurological problems, however, including dizziness.

In some ways, the idea that dizziness accompanies migraines isn't surprising. After all, nausea commonly occurs during migraines, and it is often accompanied by a feeling of motion-sickness.

These symptoms occur in at least 54 percent of patients with migraine, compared to only 30 percent of people with tension headaches. Feelings of vertigo (an illusory sense of motion) can trigger migraines, further suggesting a connection between migraines and dizziness.

While dizziness and a sensation of motion sickness are common with other forms of migraine, vestibular migraines are characterized primarily by vertigo, an unsteadiness or lack of balance, sensitivity to motion, and muffled hearing or tinnitus (ringing in the ears.)  It's thought that around 10 percent of people with migraines suffer from vestibular migraine.

Diagnosing Vestibular Migraine

To make the diagnosis of vestibular migraine, there are certain criteria that must be met. The diagnosis is usually made based on your history, your symptoms, the degree of your symptoms, the length of your episodes, and your history of migraines in the past.

Most of the time a physical exam as well as laboratory tests and imagine studies are normal.

Other possibly dangerous causes of dizziness must be ruled out before the diagnosis can be made.

Diagnostic Criteria for Vestibular Migrane

While 40 percent of people with migraines have some vestibular symptoms, there are specific symptoms which must be met to diagnose vestibular migraines.

These symptoms are defined by the Bárány Society’s Classification of Vestibular Symptoms, and include:

  • People must have a history if migraine symptoms, such as a throbbing headache, within a few hours of the dizziness, at least 50 percent of the time. (In other words, the timing of vertigo is associated with a migraine in at least half of the episodes.)
  • There must be at least five episodes which have lasted from five minutes to 72 hours.
  • There must not be another cause which could explain the symptoms.
  • Symptoms include a visual aura (for example, seeing bright lights), sensitivity to motion, photophobia (light sensitivity), phonophobia (sound induced discomfort), and vestibular symptoms.

    Vestibular symptoms include:

    • Spontaneous vertigo (If suddenly you feel like you are spinning or the room is spinning around you.)
    • Positional vertigo (Vertigo which occurs when you move or turn your head into a different position.)
    • Visually-induced vertigo (Vertigo which occurs in response to watching a moving object.)
    • Head motion induced vertigo (Vertigo which is caused by head movements.)
    • Head motion induced dizziness with vertigo (Dizziness in which there is a disturbance in spatial orientation.)

    Who Gets Vestibular Migraines?

    Vestibular migraines usually occur in people with an established history of migraines, yet it's important to note that the diagnosis of migraine headaches is underdiagnosed. Like other forms of migraine, vestibular migraine is more common in women than men. These migraines often make their appearance between the ages of 20 and 40, but can begin in childhood. For women, a worsening of symptoms is often noted in the pre-menstrual period. Vestibular migraines are known to run in families.

    The Cause and Genetics of Vestibular Migraine

    The causes of migraine are generally not well understood, and vestibular migraine even less so. The belief is that abnormal brainstem activity spreads to change how we normally interpret our senses, including pain, as well as altering blood flow through the arteries in the head.

    In medical terms, there are mechanisms that are thought to be activated which link the trigeminal system (a part of the brain activated during migraines) to the vestibular system.

    Genetic studies of people with vertigo and migraine have revealed an increased chance of genes like the CACNA1A gene, a cause of episodic ataxia type 2. Other genes that are connected with both vertigo and migraine include ATP1A2 (also involved with episodic ataxia) and SCN1A. All of these genes are related to ion channels that control how electricity spreads in the brain.

    Treatment of Vestibular Migraine

    The treatment of a vestibular migraine is similar to other migraine therapies, and usually includes a combination of several treatment modalities. With regard to medications, often times the drugs which relieve dizziness do not relieve the headaches, and vice versa. Treatments include:

    • Avoidance of triggers - One of the first and most important steps is to recognize (and avoid when possible) anything which triggers the migraines. This may include certain foods, sleep loss, or bright lights for starters. Visual motion may sometimes trigger a vestibular migraine.
    • Lifestyle measures - From sleep hygiene, to habits, lifestyle measures can make a big difference for people living with migraines. Many people with migraines, for example, find it helpful to awaken and go to the sleep at the same time each day, even on weekends.
    • Acute migraine medications (abortive migraine medications.)
    • Chronic migraine medications (preventive migraine medications) - There are several classes of medications which may be tried in order to reduce the number or frequency of migraine episodes. These can include anti-seizure medications such as Neurontin (gabapentin), beta-blockers, tricyclic antidpressants, calcium channel blockers, and more.
    • Nausea medications (antiemetics) such as Thorazine or Reglan.
    • Dizziness medications such as meclizine.
    • Behavioral approaches - Behavioral therapies for migraine, such as relaxation therapy, cognitive behavioral therapy, and biofeedback are an important part of treatment.
    • Physical therapy to help with instability while walking with a vestibular migraine.

    Disorders Related to Vestibular Migraine

    There are other conditions which may be similar or overlap with vestibular migraine. These include:

    • Basilar migraine - Basilar migraine, or Bickerstaff's syndrome, is a related type of migraine that also causes vertigo, but usually resolves by early adulthood. The term basilar refers to the basilar artery which supplies much of the brainstem with blood, including centers for balance. Unlike vestibular migraine, basilar migraine can cause other symptoms such as double vision, slurred speech, hearing changes, clumsiness, sensory changes, and even loss of consciousness.
    • Meniere disease - Meniere disease is a disorder of the inner ear that causes both vertigo and tinnitus. Meniere disease may be confused with a vestibular migraine. Furthermore, it's not uncommon for someone to have both disorders. About 45 percent of people with Meniere disease have at least one migraine-type symptom during attacks of vertigo, and there's an increased risk of migraine in people with Meniere's. This suggests that the two conditions may be closely linked in origin.
    • Panic disorder - People with migraine have a 16 percent lifetime chance of developing a panic disorder, which is four times higher than people without migraine. Both conditions can give a sense of dizziness. Panic attacks can also cause chest pain, chills, nausea, a feeling of choking, sweating, numbness, tingling and more. In fact, it's not uncommon for people to have all three conditions: migraine, anxiety, and problems with balance. This is called migraine-anxiety related dizziness.
    • Motion sickness - People with migraine of all type are also more likely to suffer from motion sickness, again suggesting a connection between the vestibular system and migraines.

    What Else Could it Be? - Differential Diagnosis of Vestibular Migraines

    As noted above, a diagnosis of vestibular migraine is made only after other conditions have been excluded. This includes the conditions listed above such as Meniere disease, as well as:

    Coping with Vestibular Migraines

    Vestibular migraines can have a very significant impact on your life. Due to this impact, it's important to create a comprehensive treatment plan if you have these migraines including not only medications, but avoidance of triggers and lifestyle and behavioral approaches.

    It can be frustrating coping with these symptoms, and you may feel isolated because of them, but people with a vestibular migraine are in good company, as many people have to find ways to cope with migraines every day. There is a large community of people who can turn to each other for tips and advice. You may have a local support group in your community, but there are many online vestibular migraine support communities available as well which can provide support, as well as help you learn about the latest research on the condition.

    Sources:

    Dieterich, M., Obermann, M., and N. Celebisoy. Vestibular Migraine: The Most Frequent Entity of Episodic Vertigo. Journal of Neurology. 2016. 263 Suppl 1:S82-9.

    Sohn, J. Recent Advances in the Understanding of Vestibular Migraine. Behavioral Neurology. 2016. 2016:1801845.

    Tedeschi, G., Russo A., Conte, F., Laura, M., and A. Tessitore. Vestibular Migraine Pathophysiology: Insights from Structural and Functional Neuroimaging. Neurological Sciences. 2015. 36 Suppl 1:37-40.

    von Brevern, M., and T. Lemert. Vestibular Migraine. Handbook of Clinical Neurology. 2016. 17:301-16.

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