Vestibular Migraine: Diagnostic Criteria and Treatment

Vestibular migraine lifetime prevalence is 1-2.7%; accounts for 7-10% of adult dizziness presentations. Women 3-5× more often. Typical onset 35-45 years; migraine history usually predates from teens or 20s, and the vestibular component is added later.

Often called "underrecognised" — symptoms are vague, attack duration varies, headache may be absent; many patients are undiagnosed for years. Cycling between ENT, neurology, cardiology, and psychiatry is common.

Clinical picture variable. Vestibular attack types: (1) spontaneous vertigo — room-spinning sensation, 5 min-72 h; (2) positional vertigo — provoked by head positions (can be confused with BPPV; nystagmus pattern differs); (3) visually induced vertigo — busy environments (mall, supermarket, traffic), screens; (4) motion-induced unsteadiness — walking, turning, head movement.

Duration variable: short (5-30 min — positional) or long (hours-days — spontaneous). Bárány criteria require 5 min - 72 h. In chronic (>3 months daily dizziness) consider mal de débarquement, PPPD (persistent postural-perceptual dizziness), or overlap.

Associated symptoms: nausea/vomiting (prominent in attack), photophobia (light sensitivity), phonophobia (sound sensitivity), aura — visual (scintillation, bright spots), sensory, motor; headache; concentration difficulty; fatigue (post-attack 1-2 days); mood disturbance.

Downward movement-, bright-light-, crowded environment-induced dizziness is typical for vestibular migraine. These features differentiate from other vertigo causes. We expand on the clinical framework in our otology and hearing centre.

Vestibular migraine diagnosis is clinical — Bárány Society / International Headache Society 2012 criteria. Four elements: (1) at least 5 vestibular attacks (moderate-severe, 5 min-72 h); (2) ICHD-3 migraine diagnosis (current or past); (3) migraine features in ≥50% attacks (headache, visual aura, photo/phonophobia); (4) not better explained otherwise.

"Probable vestibular migraine" subcategory: not meeting all criteria but ≥3 vestibular attacks and migraine features. Managed similarly to definite vestibular migraine.

Differential diagnosis is critical. Key alternatives and discriminating features: (a) BPPV — positional, very brief attack (seconds), positive Dix-Hallpike, resolves with manoeuvre; (b) Meniere — attack 20 min-12 h, fluctuating hearing loss, tinnitus, fullness; (c) vestibular neuritis — single attack lasting days then resolves, hearing normal; (d) central vertigo — brainstem/cerebellar lesion, other neurology (dysarthria, visual, extremity weakness); (e) orthostatic hypotension — postural with BP drop; (f) PPPD — chronic (>3 months) daily dizziness, anxiety/depression overlap, visual motion intolerance dominant.

Per Bárány, if hearing loss present consider Meniere; very brief attack (seconds) BPPV; single long episode vestibular neuritis; central signs require MRI.

Examination: full ENT + neurology. Between attacks usually no neurology. Sometimes mild nystagmus on lateral gaze or positional; VOR may be slightly reduced.

Tests for exclusion not confirmation: audiometry (Meniere or hearing disorder), vestibular battery (VNG/ENG, calorics, video head impulse — vHIT; differentiates Meniere/neuritis), MRI (rules out central lesion, acoustic neuroma; if atypical findings at first presentation). In vestibular migraine, tests usually normal or non-specific.

History items: triggers (sleep, stress, foods, hormones), attack frequency + duration, headache co-occurrence, photo/phonophobia, family migraine history, prior treatments and responses, QoL impact (work, social, driving).

Acute treatment is symptom-directed. Started at attack onset or early for best effect.

Triptans (sumatriptan 50-100 mg po or nasal spray, rizatriptan 10 mg, almotriptan 12.5 mg, eletriptan 40 mg): effective when headache component is prominent. Triptans are 5-HT1B/1D agonists — act on vascular and trigeminal components of migraine. Most effective when taken early. Contraindications: ischaemic heart disease, uncontrolled hypertension, pregnancy (especially 1st trimester).

Antiemetics: prochlorperazine 5-10 mg po or suppository, metoclopramide 10 mg po or IM, ondansetron 4-8 mg po. Both nausea/vomiting control and vestibular sedation. Alone or combined with triptan.

Benzodiazepines: diazepam 5-10 mg, clonazepam 0.5-1 mg, lorazepam 0.5-1 mg — severe attack vestibular sedation. Short-term and infrequent — dependence risk + chronic use impairs vestibular compensation.

Antihistamines: meclizine (Antivert) 25-50 mg, dimenhydrinate — mild-moderate attacks. Often alternative or combined with benzodiazepine.

Attack-onset steps: move to a calm setting, leave bright/crowded space, focus on a fixed point, slow deep breathing, fluids, oral medication. If vomiting, use suppository (prochlorperazine) or IM (metoclopramide).

NSAIDs: ibuprofen 600-800 mg, naproxen 500 mg — mild-moderate attack. Help migraine component; limited specific vestibular effect.

When to go to ER? Attack >72 h, severe dehydration (persistent vomiting), neurology (dysarthria, visual, extremity weakness — central concern), atypical severe headache ("worst headache of my life"), young patient — pregnancy or postpartum. Step-by-step details: vertigo page.

Prophylaxis indications: attack frequency ≥4/month, high severity (work loss, social impact), acute treatment insufficient/contraindicated, patient preference. Trial 3-6 months, assess efficacy, switch agent if unsuccessful.

Beta-blockers (propranolol 80-160 mg/day, metoprolol 50-200 mg/day): commonest first choice in vestibular migraine. Long migraine experience, addresses vestibular component. Side effects: fatigue, bradycardia, hypotension, depression (in predisposed), sleep disturbance. Contraindications: severe asthma, AV block, severe peripheral vascular disease.

Topiramate (50-100 mg/day, titrated 12.5 → 25 → 50 mg): migraine and epilepsy. Effective if tolerated. Side effects: paraesthesia (fingers/lips), cognitive slowing, weight loss, renal stones, rare glaucoma risk.

Amitriptyline (25-75 mg at night): tricyclic; low-dose migraine prophylaxis + sleep regulation + comorbid depression/anxiety. In older patients beware anticholinergic effect (urinary retention, dry mouth, confusion).

Valproate (250-1000 mg/day): effective migraine prophylaxis; second-line in vestibular migraine. Side effects: weight gain, tremor, alopecia, hepatic toxicity (monitor); contraindicated in women of childbearing potential (neural tube defect risk).

Other options: calcium channel blocker (flunarizine — common in Europe; not available in US), CGRP monoclonal antibodies (erenumab, fremanezumab, galcanezumab — new migraine prophylaxis; limited but promising data in vestibular migraine), magnesium, riboflavin (B2 high-dose 400 mg/day), CoQ10.

Lifestyle is fundamental: regular sleep (7-8 h), regular meals (fasting trigger), hydration, caffeine moderation, alcohol limit, trigger foods (chocolate, cheese, red wine, MSG, glutamate) identification + reduction (trigger diary), stress management (meditation, yoga, physio), regular exercise (aerobic 3-5×/week).

Vestibular rehabilitation: between-attack balance and head-movement exercises. Effective for chronic dizziness, visual motion intolerance, functional limitation. Physio-led with home programme.

Comorbidity management: anxiety + depression frequently coexist; treatment (SSRI/SNRI, psychotherapy) improves both mental health and migraine. Consider PPPD overlap in chronic dizziness + anxiety scenarios.

Prognosis: most patients see marked reduction in attack frequency + severity with appropriate treatment. Full remission is uncommon but good QoL achievable. Hormonal changes (perimenopause) may worsen; menopause often brings improvement. Related reading: our patient testimonials.