Symptoms of Vestibular Migraine
Vestibular migraine presents with recurrent episodes of moderate to severe vestibular symptoms (vertigo, dizziness, head-motion intolerance) lasting 5 minutes to 72 hours, accompanied by migraine features (headache with pulsating quality/unilateral location/moderate-severe intensity, photophobia, phonophobia, or visual aura) in at least 50% of attacks. 1
Core Vestibular Symptoms
The vestibular manifestations are diverse and include:
- Spontaneous vertigo - the sensation of spinning or rotation
- Positional vertigo - triggered by changes in head position
- Visually-induced dizziness - discomfort with visual stimulation or busy environments
- Head motion-induced dizziness with nausea - symptoms provoked by head movement 1, 2
Symptom intensity matters clinically: "moderate" symptoms interfere with but don't prohibit daily activities, while "severe" symptoms prevent continuation of daily activities 1
Episode Duration Pattern
The temporal profile is highly variable but diagnostically important:
- 30% have episodes lasting minutes
- 30% have attacks lasting hours
- 30% have attacks over several days
- 10% have brief attacks (seconds) that recur repeatedly during head motion, visual stimulation, or positional changes 1
The core episode rarely exceeds 72 hours, though some patients may take up to 4 weeks to fully recover 1
Migraine-Associated Features
At least one of these must occur with ≥50% of vestibular episodes 1:
Headache Characteristics (need ≥2):
- Unilateral location
- Pulsating quality
- Moderate to severe pain intensity
- Aggravation by routine physical activity
Sensory Hypersensitivities:
- Photophobia (light sensitivity)
- Phonophobia (sound-induced discomfort) - must be distinguished from recruitment in hearing loss 1
Visual Aura:
- Bright scintillating lights or zigzag lines
- Often with scotoma interfering with reading
- Typically expands over 5-20 minutes
- Lasts <60 minutes
- Often (not always) restricted to one hemifield 1
Auditory Symptoms
Hearing-related symptoms frequently accompany vestibular migraine attacks and may mimic Menière's disease 3. These can include tinnitus, ear fullness, or fluctuating hearing loss, though hearing loss is less common than in Menière's disease 1
Interictal (Between-Attack) Symptoms
Many patients experience persistent symptoms between discrete attacks 4:
- Persistent head-motion intolerance
- Ongoing visually-induced dizziness
- Increased susceptibility to motion sickness
- Positional vertigo
- Migraine-associated sensory hypersensitivities
These interictal manifestations may increase over time even when attack frequency decreases, supporting a spectrum-based view of the disorder 4
Associated Comorbidities
- Mood disorders, particularly anxiety, are commonly found 3
- Premonitory symptoms including brain fog and executive slowing 5
- Persistent postural-perceptual dizziness may coexist 5
Critical Diagnostic Requirement
A current or previous history of migraine (with or without aura) according to International Classification of Headache Disorders criteria is mandatory for diagnosis 1. At least 5 episodes meeting the full criteria are required for definitive diagnosis 1, 2
Important Clinical Pitfall
Headache is NOT required during every vestibular attack - the diagnosis can be made if other migraine features (photophobia, phonophobia, visual aura) are present instead 1. Different symptoms may occur during different episodes, and associated symptoms may occur before, during, or after the vestibular symptoms 1