What is the relationship between the patient's symptoms and a diagnosis of vestibular migraine?

Vestibular Migraine Diagnosis in Relation to Patient Symptoms

Vestibular migraine should be strongly considered as a diagnosis when a patient presents with recurrent episodes of vestibular symptoms accompanied by migraine features, even if headache is not always present during vertigo attacks. 1

Diagnostic Criteria for Vestibular Migraine

According to the Barany Society diagnostic criteria, vestibular migraine is characterized by:

1. At least 5 episodes of vestibular symptoms of moderate to severe intensity lasting 5 minutes to 72 hours
2. Current or previous history of migraine with or without aura
3. One or more migraine features during at least 50% of vestibular episodes:
   • Headache with specific characteristics (unilateral, pulsating, moderate/severe, aggravated by activity)
   • Photophobia and phonophobia
   • Visual aura
4. Not better accounted for by another vestibular or headache diagnosis 1

Key Clinical Manifestations to Evaluate

When assessing a patient for vestibular migraine, look for:

• Vestibular symptoms: Spontaneous vertigo, positional vertigo, visually-induced vertigo, head motion-induced dizziness, or head motion intolerance 1, 2
• Temporal relationship: Vestibular symptoms occurring during or around migraine episodes 1
• Migraine features: Even without headache, look for photophobia, phonophobia, visual auras, or motion sensitivity 1, 2
• Duration patterns: Vertigo episodes can vary widely in duration (minutes to days) 1
• Auditory symptoms: Some patients may report tinnitus or aural fullness, which can mimic Ménière's disease 1, 2

Distinguishing Features from Other Vestibular Disorders

Vestibular migraine differs from Ménière's disease in several important ways:

• In vestibular migraine, "hearing loss" is often a perception of difficulty processing sound rather than actual hearing loss 1
• Auditory complaints in migraine are typically bilateral rather than unilateral 1
• Visual auras may occur before, during, or after attacks 1
• Hearing loss, if present, is typically mild or absent and stable over time (unlike the fluctuating hearing loss in Ménière's disease) 1
• Motion intolerance and light sensitivity are more characteristic of vestibular migraine 1

Diagnostic Approach

1. Detailed history: Focus on the relationship between vestibular symptoms and migraine features
2. Assess for migraine history: Even if headaches don't accompany every vertigo episode
3. Evaluate triggers: Light sensitivity, motion intolerance, specific head movements 1
4. Duration patterns: Vestibular migraine can present with short (<15 minutes) or prolonged (>24 hours) periods of vertigo 1

Important Clinical Considerations

• Imaging is not required to diagnose vestibular migraine but may be used to rule out other causes 1
• Vestibular migraine is often underdiagnosed despite being the most common neurologic cause of vertigo in adults 2, 3
• Physical examination and laboratory testing are usually normal in vestibular migraine 4
• The condition accounts for approximately 7% of patients seen in dizziness clinics and 9% of patients seen in headache clinics 3

Common Pitfalls and Caveats

• Misdiagnosis: Vestibular migraine is often misdiagnosed as Ménière's disease, especially when auditory symptoms are present 1
• Absence of headache: Headache may be absent during acute vertigo attacks, requiring identification of other migraine features 5
• Overlapping conditions: It's possible for patients to have both vestibular migraine and Ménière's disease concurrently 1
• Treatment response: Lack of response to typical migraine medicines does not rule out vestibular migraine 1

By carefully evaluating the pattern of vestibular symptoms and their relationship to migraine features, clinicians can accurately diagnose vestibular migraine and initiate appropriate treatment, improving patient outcomes in terms of morbidity and quality of life.