Can a migraine cause only sensory deficits with dizziness?

Migraine Can Present with Only Sensory Deficits and Dizziness

Yes, migraine can manifest with only sensory deficits and dizziness, without headache, in the form of vestibular migraine. This is a recognized clinical entity that can be challenging to diagnose due to its variable presentation.

Vestibular Migraine: Understanding the Presentation

Vestibular migraine (VM) is characterized by:

• Episodes of vestibular symptoms (dizziness/vertigo) of moderate to severe intensity
• Current or previous history of migraine with or without aura
• At least 50% of vestibular episodes associated with migraine features 1

The presentation can include:

• Attacks lasting minutes to hours or even days 2
• Sensory symptoms without headache
• Dizziness that may be described as rotatory vertigo or a feeling of unsteadiness 3
• Often accompanied by motion sensitivity and postural instability 4

Diagnostic Criteria and Differentiation

According to the International Headache Society criteria, VM requires:

• At least 5 episodes with vestibular symptoms
• Current or previous history of migraine
• One or more migraine features with vestibular episodes 1

Key distinguishing features from other conditions:

• Ménière's Disease: VM typically has less hearing loss (mild or absent) and more stable hearing over time compared to Ménière's disease 2
• Stroke: Unlike posterior circulation stroke, VM rarely presents with other focal neurologic deficits 2
• BPPV: VM episodes typically last longer than the brief seconds of vertigo seen in BPPV 2

Pathophysiological Mechanisms

Two proposed mechanisms explain different presentations of VM 4:

1. Short-duration attacks (minutes to 2 hours): Similar mechanism as other migraine aura phenomena - spreading cortical depression and/or transient vasospasm

2. Longer-duration episodes (days): Release of neuroactive peptides into vestibular structures, causing increased baseline firing of primary afferent neurons and heightened sensitivity to motion

Clinical Pearls and Pitfalls

Important considerations:

• VM is the most common cause of spontaneous recurrent vertigo 5
• Patients with VM often have a history of motion sickness 3
• Sensory symptoms may occur without headache, especially in patients with established migraine history
• The delay between classic migraine onset and vertigo symptoms may be several years 3

Common pitfalls:

• Misdiagnosing VM as "sinus headache" when autonomic symptoms are present 1
• Confusing VM with Ménière's disease, which has more prominent hearing fluctuations 2
• Failing to recognize VM in patients with dizziness but no current headache 1
• Overlooking VM when evaluating isolated sensory symptoms without headache

Evaluation Approach

When evaluating patients with sensory deficits and dizziness:

1. Determine if there are "red flags" suggesting secondary causes (sudden onset, atypical symptoms, focal deficits) 1

2. Assess for migraine history, including:

   • Previous migraine diagnosis
   • Family history of migraine
   • Motion sensitivity
   • Photophobia or phonophobia during episodes

3. Evaluate vestibular symptoms:

   • Duration (seconds, minutes, hours, days)
   • Triggers (positional changes, specific movements)
   • Associated symptoms (hearing changes, tinnitus, aural fullness)

4. Consider neuroimaging only if:

   • Features suggest central vertigo
   • High baseline risk for stroke
   • HINTS examination (when available) suggests central cause 2

In summary, sensory deficits with dizziness can be the sole manifestation of migraine, particularly in patients with a history of migraine or migraine risk factors. Recognizing this presentation is crucial for proper diagnosis and management.