Does a vestibular migraine present with nystagmus at rest?

Vestibular Migraine and Nystagmus at Rest

Vestibular migraine typically does not present with nystagmus at rest (baseline nystagmus) but rather with positional nystagmus during attacks. 1, 2

Distinguishing Features of Nystagmus in Vestibular Migraine

Vestibular migraine presents with characteristic patterns of nystagmus that help differentiate it from other vestibular disorders:

• During attacks (ictal):

  • Positional nystagmus is present in 100% of symptomatic patients when fixation is blocked 2
  • Spontaneous nystagmus may be observed in approximately 71% of patients during attacks 3
  • Nystagmus is typically low-velocity (mean 5.3 ± 9.0°/s for spontaneous, 10.4 ± 5.8°/s for positional) 3
  • Direction can be variable - horizontal (49.5%), vertical (21.8%), or torsional 3

• Between attacks (interictal):

  • Spontaneous nystagmus is uncommon (14.9% of patients) 3
  • When present, interictal nystagmus is typically low velocity (<3°/s in 91.8% of cases) 3
  • Positional nystagmus may persist in about 55.4% of patients between attacks 3

Diagnostic Significance

The absence of baseline nystagmus at rest is an important diagnostic feature that helps distinguish vestibular migraine from central causes of vertigo. According to clinical practice guidelines:

• Baseline nystagmus manifesting without provocative maneuvers is more suggestive of a central neurological cause rather than peripheral vestibular disorders or vestibular migraine 1
• Direction-changing nystagmus occurring without changes in head position (periodic alternating nystagmus) suggests a central cause 1
• Down-beating nystagmus on the Dix-Hallpike maneuver is more indicative of a central etiology 1

Clinical Pearls for Vestibular Migraine Diagnosis

When evaluating a patient with suspected vestibular migraine, look for:

• Positional nystagmus that is typically:

  • Low velocity
  • Sustained
  • Reduced by visual fixation
  • Can be horizontal, vertical, or torsional 2
  • Elicited in Dix-Hallpike or supine head positions 4
  • No latency period (unlike BPPV) 4
  • Non-fatigable (unlike BPPV) 4

• Associated features:

  • History of migraine headaches (though approximately one-third of patients may present with isolated vertigo episodes) 5
  • Normal vestibular test results between attacks (caloric testing, video head impulse test) 3
  • Resolution of nystagmus when the patient is symptom-free 2

Common Pitfalls in Diagnosis

• Misdiagnosis risk: Vestibular migraine is often misdiagnosed due to its variable presentation and the fact that approximately one-third of patients present with monosymptomatic attacks of vertigo without headache 5

• Overlapping symptoms: Be alert for signs suggesting central rather than peripheral vertigo, including downbeating nystagmus, direction-changing nystagmus, persistent nystagmus, failure to respond to repositioning maneuvers, associated neurological symptoms, and severe imbalance out of proportion to vertigo 6

• Differential diagnosis: Important to distinguish from Menière's disease, BPPV, vestibular neuritis, and central causes of vertigo 6

In summary, while vestibular migraine can present with nystagmus during attacks, the presence of baseline nystagmus at rest (without provocative maneuvers) should raise suspicion for a central neurological cause rather than vestibular migraine.