What are the characteristics of vestibular migraine?

Vestibular Migraine Characteristics

Vestibular migraine is characterized by at least 5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours, occurring in patients with a current or prior history of migraine, with at least one migraine feature (headache, photophobia, phonophobia, or visual aura) present during at least 50% of the dizzy episodes. 1, 2

Core Diagnostic Criteria

The Barany Society diagnostic criteria, endorsed by multiple otolaryngology guidelines, define vestibular migraine with four essential components 2:

Episode Characteristics

• Frequency: Minimum of 5 episodes required for diagnosis
• Duration: Episodes last 5 minutes to 72 hours (highly variable)
  • ~30% experience episodes lasting minutes
  • ~30% have attacks lasting hours
  • ~30% have attacks over several days
  • ~10% have brief seconds-long attacks that recur repeatedly during head motion or visual stimulation 2
• Intensity: Moderate (interferes with but does not prohibit daily activities) or severe (daily activities cannot be continued) 2

Vestibular Symptom Profile

The vestibular symptoms include 2:

• Spontaneous vertigo: Internal spinning or swaying sensation
• Positional vertigo: Triggered by head position changes
• Visually induced vertigo: Provoked by complex visual stimuli
• Head motion-induced vertigo: Occurring with head movement

Required Migraine Connection

Two mandatory elements must be present 1, 2:

1. Migraine history: Current or previous diagnosis of migraine with or without aura according to International Headache Society criteria

2. Migraine features during vestibular episodes: At least one of the following must occur during ≥50% of dizzy episodes:

   • Migrainous headache (unilateral, pulsating, moderate-to-severe intensity, aggravated by physical activity)
   • Photophobia AND phonophobia (both required if using this criterion)
   • Visual aura (bright scintillating lights, zigzag lines, scotoma expanding over 5-20 minutes, lasting <60 minutes)

Exclusion Requirement

Other vestibular or neurological causes must be ruled out by appropriate investigations 1, 2.

Epidemiology and Clinical Impact

Vestibular migraine is very common, with a lifetime prevalence of 3.2% in the general population and accounts for approximately 14% of all vertigo cases. 1 It represents one of the most frequent causes of episodic vertigo in specialty clinics 2.

Key Distinguishing Features from Other Vestibular Disorders

Differentiation from BPPV

• Duration: Vestibular migraine episodes last minutes to hours/days, whereas BPPV episodes last seconds 1
• Trigger pattern: Vestibular migraine is a spontaneous episodic vestibular syndrome, not purely positional 1
• Associated symptoms: Migraine features (headache, photophobia, phonophobia, aura) are present in vestibular migraine but absent in classic BPPV 1

Differentiation from Ménière's Disease

• Hearing loss pattern: Vestibular migraine typically has mild or absent hearing loss that remains stable over time, whereas Ménière's disease features fluctuating hearing loss, tinnitus, and aural fullness in the affected ear 2
• Attack timing: Vestibular migraine attacks may be shorter (minutes) or longer (>24 hours) than the typical 20-minute to 24-hour Ménière's disease attacks 2
• Sensory features: Photophobia is more prominent than visual aura in vestibular migraine; motion intolerance and light sensitivities are characteristic 2

Clinical Spectrum and Presentation Variability

The clinical presentation is heterogeneous 3, 4:

• Spontaneous persistent vertigo/dizziness
• Isolated positional vertigo
• Extreme sensitivity to self-motion and visual motion
• Accompanying symptoms: nausea, vomiting, phonophobia, photophobia

Interictal Manifestations

Many patients experience persistent vestibular symptoms between attacks, including 5:

• Head-motion intolerance
• Visually induced dizziness
• Positional vertigo
• Increased motion sickness susceptibility
• Migraine-associated sensory hypersensitivities

These interictal symptoms may increase over time even when attack frequency decreases, supporting a spectrum-based view of the disorder 5.

Common Clinical Pitfalls

1. Bilateral headache does not exclude migraine: Approximately 40% of migraine patients report bilateral pain during attacks 6

2. Headache may be absent during vestibular episodes: The diagnosis requires migraine features in only 50% of episodes, not all episodes 2

3. Diagnostic testing is typically normal: MRI and quantitative vestibular testing usually reveal no structural abnormalities; there is no definitive diagnostic test 3, 4

4. Probable vestibular migraine: Patients meeting only criterion B (migraine history) OR criterion C (migraine features during episodes) but not both are classified as "probable vestibular migraine" 2

5. Post-traumatic presentation: Post-head trauma vestibular migraine has been described and should be considered in the appropriate clinical context 1

Pathophysiological Understanding

Current evidence indicates vestibular migraine involves 4:

• Trigeminovascular activation
• CGRP signaling dysregulation
• Central sensitization
• Altered vestibulo-thalamo-cortical networks
• Cerebellar compensation mechanisms

This represents a central vestibular disorder rather than a primary peripheral vestibular pathology 5.