Vertigo is a type of dizziness often described as the feeling that the body or surrounding environment is spinning or tilting, even though both are actually stationary. People with migraine frequently report experiencing episodes of dizziness and vertigo, so experts have long suspected that there is a connection between them. Recent research in this area has provided enough evidence for the proposal of a new possible category – vestibular migraine – to describe vertigo that may actually be caused by migraine. This phenomenon was formerly known as “migraine-associated vertigo/dizziness” or “migrainous vertigo.”
The International Headache Society, working together with the Bárány Society for vestibular research, has included vestibular migraine in the 2013 version of The International Classification of Headache Disorders, 3rd Edition (ICHD-III).1 It is important to note that vestibular migraine is not currently recognized by the ICHD-III as an actual migraine type, but rather an “episodic syndrome that may be associated with migraine.” Vestibular migraine is listed in the appendix of the ICHD-III, which means that researchers will continue to investigate it over the next few years. If enough evidence is gathered, then it may be included as an official migraine classification in the next edition of the guidelines.
Symptoms of vestibular migraine
In the vestibular system, the inner ear sends sensory signals to the brain that help to coordinate eye movements and to regulate a person’s sense of balance and spatial position. Problems that affect the vestibular system can cause symptoms like dizziness and vertigo. The ICHD-III proposes a set of vestibular symptoms associated with vestibular migraine1:
- Spontaneous vertigo includes both internal vertigo, the false feeling that your body is moving, and external vertigo, which is the false feeling that your external environment is spinning or flowing.
- Positional vertigo occurs after a change in head position.
- Visually induced vertigo is caused by seeing the movement of something complex or large.
- Head motion-induced vertigo happens during movement of the head.
- Head motion-induced dizziness with nausea involves dizziness that feels like spatial disorientation.
The duration of these vestibular symptoms can vary widely, lasting seconds, minutes, hours, or even days or weeks. For about a third of patients, the episodes last for only a few minutes. For another third, the attacks last for hours and for the final third, the attacks can persist for several days or more. Patients frequently experience nausea during vestibular migraine attacks and around 40% of patients report hearing-related symptoms such as temporary hearing loss or ringing in the ears.2
Diagnosing vestibular migraine
According to the ICHD-III, vestibular migraine should be diagnosed in patients (with a current or past history of migraine with or without aura) who have experienced at least five attacks of moderate- or severe-intensity vestibular symptoms that lasted between 5 minutes and 72 hours. At least half of those five attacks must include at least one of the following symptoms:
- Headache with at least two of these features: located on one side only; pulsating quality; moderate/severe intensity; worsened by normal physical activity
- Photophobia (sensitivity and discomfort caused by light) and phonophobia (discomfort caused by sounds)
- Visual aura
A patient can experience different symptoms or combinations of symptoms during different episodes; these symptoms can also occur at the same time, before, or after the vestibular symptoms.
Vestibular migraine is estimated to occur in about 1% of the population, though researchers believe that it often goes undiagnosed in many patients around the world. Like other kinds of migraine, women are more likely than men to have vestibular migraine. Most patients experience non-vestibular migraine earlier in life before the first vestibular migraine attack, which can happen at any age from childhood through late adulthood. 2
Management of vestibular migraine
Individual vestibular migraine attacks are usually only treated if they are acute and long-lasting. Treatment often involves the same kinds of medications used to treat acute vertigo attacks: anti-vertiginous drugs (eg, promethazine), anti-nausea drugs (eg, metoclopramide, dimenhydrinate, or benzodiazepines), and/or antihistamines.2,3 Unfortunately, there is currently a lack of clinical trial data regarding the specific treatment of vestibular migraine. For example, it is not known whether conventional treatments for other types of migraine such as triptans, NSAIDs, and ergots are effective and safe for treating vestibular migraine.3 This is an important area for future research.
Due to this lack of data and because vestibular symptoms are often relatively brief, non-pharmaceutical approaches for treating and preventing vestibular migraine attacks are often recommended by physicians. The first important step is for the patient to receive the correct diagnosis and to understand how migraine can cause these vestibular symptoms, in order to lessen anxiety and fear during attacks. As suggested for managing other types of migraines, patients should keep a diary to record the details of symptoms and attacks. Identifying and avoiding potential triggers, such as disrupted sleeping and eating patterns, is also recommended.
Because dizziness and vertigo can occur with other types of migraine or with different disorders related to the vestibular system, it is important for clinicians to figure out exactly what is causing the symptoms. For example, vertigo is reported by more than 60% of migraine with brainstem aura (MBA) patients. However, the ICHD-III does not classify the kind of vertigo associated with vestibular migraine as a “migraine aura,” because it usually does not meet the criteria for an aura symptom: it rarely occurs immediately prior to headache and often lasts for more than an hour. Also, a diagnosis of MBA requires another brainstem symptom in addition to vertigo. Fewer than 1 in 10 patients with vestibular migraine fit the description for MBA, so the ICHD-III classifies them as separate disorders even though some patients may meet the conditions for both.
Vestibular migraine and Ménière’s disease also share a common set of symptoms that includes vertigo, headache, sensitivity to light/sound, hearing loss, and ringing in the ears. The two conditions can appear very similar and a patient can be diagnosed with both disorders separately. But the key difference is that Ménière’s disease patients suffer from profound hearing loss, while hearing loss related to vestibular migraine is temporary. In children, a syndrome called benign paroxysmal vertigo (recurring brief attacks of vertigo) is thought to be an indication that migraine will develop later in life. Researchers are working to further understand the relationships among these distinct but overlapping conditions.
- Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 3rd edition. Cephalalgia. 2013;33:629-808.
- Lempert T. Vestibular Migraine. Semin in Neurol. 2013;33(3):212-218.
- Bisdorff A. Management of vestibular migraine. Ther Adv Neurol Disord. 2011;4(3):183-191.