What is a vestibular migraine?

Vestibular Migraine: Definition and Diagnostic Criteria

Vestibular migraine is the most common neurologic cause of vertigo in adults, characterized by recurrent vestibular attacks often accompanied by migraine headaches and other migraine symptoms, affecting approximately 1-3% of the general population and 10-30% of patients seeking treatment for dizziness. 1

Diagnostic Criteria

According to the Barany Society diagnostic criteria for vestibular migraine, the following must be present 2:

1. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
2. Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders
3. One or more migraine features with at least 50% of the vestibular episodes:
   • Headache with at least two of: one-sided location, pulsating quality, moderate/severe intensity, aggravation by routine physical activity
   • Photophobia and phonophobia
   • Visual aura
4. Not better accounted for by another vestibular or headache diagnosis

Clinical Presentation and Characteristics

Vestibular Symptoms

• Duration of episodes is highly variable 2:
  • About 30% of patients have episodes lasting minutes
  • 30% have attacks lasting hours
  • 30% have attacks over several days
  • 10% have attacks lasting seconds only (occurring repeatedly during head motion or visual stimulation)

Associated Features

• Vestibular symptoms may include spontaneous vertigo, triggered vertigo, positional vertigo, and head-motion dizziness 3
• Migraine features often accompany vestibular symptoms, including:
  • Headache (though not always present)
  • Photophobia (light sensitivity)
  • Phonophobia (sound sensitivity)
  • Visual auras (bright scintillating lights or zigzag lines) 2

Important Distinctions

• Unlike Ménière's disease, hearing loss in vestibular migraine is typically mild or absent and stable over time 2
• Vestibular migraine patients often report motion intolerance and light sensitivity 2
• About one-third of patients present with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms 4

Differential Diagnosis

Vestibular migraine must be distinguished from other vestibular disorders 2, 5:

1. Ménière's disease - characterized by fluctuating hearing loss, tinnitus, and aural fullness with episodes lasting 20 minutes to 12 hours
2. BPPV - brief episodes (<1 minute) triggered by position changes
3. Vestibular neuritis/labyrinthitis - prolonged vertigo (>24 hours) with acute onset
4. Stroke/TIA - continuous dizziness with neurological symptoms
5. Migraine with brainstem aura - requires 2 brainstem symptoms with aura symptoms limited to 5-60 minutes 2

Pathophysiology

The precise mechanisms of vestibular migraine are not fully understood, but may involve 6:

• Neuroanatomical pathways to and from central vestibular structures
• Neurochemical modulation via the locus coeruleus and raphe nuclei

Clinical Pitfalls to Avoid

1. Failure to recognize vestibular migraine due to its variable presentation
2. Confusing with Ménière's disease, especially when auditory symptoms are present
3. Missing stroke in older adults with acute vestibular symptoms 5
4. Premature diagnostic closure without considering the full differential diagnosis 5

Vestibular migraine has evolved into a recognized medical entity over the last decade and is now considered the most common cause of spontaneous recurrent episodic vertigo, accounting for approximately 10% of patients with vertigo and dizziness 4. Proper diagnosis is essential for appropriate management and treatment.