Are vestibular migraines a form of central vertigo?

Vestibular Migraines as a Form of Central Vertigo

Yes, vestibular migraines are considered a form of central vertigo. According to clinical guidelines, vestibular migraines should be categorized among central causes of vertigo, as they involve neurological pathways and central vestibular processing 1.

Diagnostic Classification and Pathophysiology

Vestibular migraine represents a significant cause of episodic vertigo, accounting for approximately 10% of patients with vertigo and dizziness 2. The condition is characterized by:

• Episodes of vertigo that may last from seconds to days
• Variable presentation, often without concurrent headache (in about one-third of cases)
• Higher prevalence in women
• Onset possible at any age, with peaks in young adults and between ages 60-70

The central nature of vestibular migraine is supported by clinical evidence:

• During acute episodes, 50% of patients show signs of central vestibular dysfunction 3
• Patients often exhibit spontaneous or positional nystagmus during attacks 3
• The pathophysiology likely involves neuroanatomical pathways to and from central vestibular structures 4
• Neurochemical modulation via the locus coeruleus and raphe nuclei is implicated 4

Differentiating from Peripheral Vertigo

Guidelines recommend being alert for signs that suggest central rather than peripheral vertigo 1:

• Downbeating nystagmus
• Direction-changing nystagmus
• Persistent nystagmus
• Failure to respond to repositioning maneuvers
• Associated neurological symptoms
• Severe imbalance out of proportion to vertigo

When evaluating patients with suspected vestibular migraine, the HINTS examination (Head Impulse, Nystagmus, Test of Skew) is valuable for differentiating central from peripheral causes, with abnormal results suggesting central pathology 1.

Clinical Presentation and Diagnosis

Vestibular migraine presents as a "chameleon" among episodic vertigo syndromes due to its variable clinical manifestation 2. Key diagnostic features include:

• Episodic vertigo with or without migrainous symptoms
• Temporal overlap between vestibular symptoms and migraine features (headache, photophobia, phonophobia)
• Normal physical examination and laboratory testing (used primarily to rule out other disorders)
• No objective tests, imaging, or audiologic findings that reliably diagnose the condition 5

The American Academy of Otolaryngology-Head and Neck Surgery recommends a systematic approach to determine the underlying cause of dizziness, categorizing it based on timing and triggers rather than symptom quality 1.

Management Approach

For patients with vestibular migraine, treatment should follow these guidelines:

1. Vestibular rehabilitation therapy is recommended as first-line treatment for central vestibulopathy, including vestibular migraine 1
2. Migraine-specific medications such as triptans for acute attacks 1
3. Prophylactic therapy for frequent episodes 1
4. Reassessment within 1 month after initial treatment to evaluate response 1

Common Pitfalls and Caveats

• Vestibular migraine is often underdiagnosed despite being the most common cause of spontaneous recurrent episodic vertigo 6
• It can be challenging to differentiate from Menière's disease or vestibular paroxysmia 2
• Unlike peripheral vertigo, hearing is typically not affected during attacks 3
• The evidence base for vestibular migraine treatment is of low quality, highlighting the need for randomized controlled trials 6
• Patients may present with monosymptomatic attacks of vertigo without headache, making diagnosis challenging 2

In conclusion, vestibular migraine should be recognized as a central vestibular disorder based on its pathophysiology and clinical presentation, though it can occasionally present with features suggesting peripheral vestibular involvement in a minority of cases (15% according to research) 3.