How to differentiate and manage vestibular migraine vs migraine with brainstem aura?

Differentiation and Management of Vestibular Migraine vs Migraine with Brainstem Aura

Vestibular migraine and migraine with brainstem aura are distinct neurological conditions with overlapping features, but they require different diagnostic approaches and management strategies based on their unique symptom profiles and durations.

Diagnostic Differentiation

Key Distinguishing Features

Feature	Vestibular Migraine (VM)	Migraine with Brainstem Aura (MBA)
Primary Symptoms	Vestibular symptoms with migraine features	Brainstem symptoms followed by headache
Required Symptoms	At least 5 episodes of moderate/severe vestibular symptoms	At least 2 brainstem symptoms
Duration	5 minutes to 72 hours	Aura symptoms limited to 5-60 minutes
Frequency Requirement	Current/previous history of migraine + vestibular symptoms	At least 2 attacks with brainstem aura
Diagnostic Criteria Source	Barany Society	ICHD-3

Vestibular Migraine Diagnostic Criteria 1

• At least 5 episodes with vestibular symptoms of moderate/severe intensity
• Current or previous history of migraine according to ICHD
• One or more migraine features with at least 50% of vestibular episodes
• Not better accounted for by another vestibular or ICHD diagnosis

Migraine with Brainstem Aura Diagnostic Criteria 1

• At least 2 attacks fulfilling criteria
• At least 2 brainstem symptoms (dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, decreased consciousness)
• Aura symptoms limited to 5-60 minutes in duration
• Aura accompanied or followed by headache within 60 minutes

Clinical Presentation Differences

Vestibular Migraine

• Vestibular symptoms are the predominant feature
• Duration is highly variable (minutes to days)
• Symptoms may occur before, during, after headache, or independently 2
• Most common cause of spontaneous episodic vertigo 3
• May include auditory symptoms that mimic Ménière's disease 4

Migraine with Brainstem Aura

• Requires at least two specific brainstem symptoms
• Strictly limited duration of aura (5-60 minutes)
• Symptoms may originate from cortical dysfunction rather than brainstem itself 5
• Much rarer condition (0.04% of general population) 6
• Often misdiagnosed using current criteria 6

Pathophysiological Differences

Vestibular Migraine

• Involves trigeminovascular system and vestibular pathways 7
• Genetic factors likely play a significant role, especially with unilateral auditory symptoms 7
• Patients often show cerebellar and deep white matter lesions on MRI 1

Migraine with Brainstem Aura

• May involve cerebral vascular vasospasm 1
• Some evidence suggests symptoms may actually have cortical origin rather than brainstem origin 5
• May represent a variant of typical migraine aura rather than distinct brainstem pathology 5

Management Approach

Vestibular Migraine

1. Acute Treatment:

   • Triptans for rescue treatment
   • Vestibular suppressants for vertigo symptoms
   • Antiemetics for associated nausea/vomiting

2. Preventive Treatment:

   • Pharmacologic migraine preventives:
     • Antiepileptics (topiramate, valproate)
     • Beta-blockers (propranolol, metoprolol)
     • Antidepressants (amitriptyline, venlafaxine)
   • Non-pharmacologic approaches:
     • Lifestyle modifications
     • Trigger avoidance
     • Vestibular rehabilitation when appropriate

Migraine with Brainstem Aura

1. Acute Treatment:

   • Similar to typical migraine with aura
   • Caution with triptans (historically contraindicated but evidence suggests they may be safe)
   • Antiemetics and analgesics for symptom control

2. Preventive Treatment:

   • Standard migraine preventives as above
   • Close monitoring due to rarity of condition

Clinical Pitfalls and Caveats

• Misdiagnosis: Current diagnostic criteria for migraine with brainstem aura are too open and may lead to overdiagnosis 6
• Overlap with other conditions: VM must be differentiated from Ménière's disease, BPPV, vestibular neuritis, and posterior circulation ischemia 3
• Treatment response: Lack of response to migraine medications does not rule out VM 1
• Comorbidities: Mood disorders, particularly anxiety, are common in VM and should be addressed 4
• Destructive interventions: Should be avoided in suspected VM cases, even when overlapping with Ménière's disease, until adequate trials of medical therapy 1

Diagnostic Algorithm

1. Assess vestibular symptoms:

   • Duration (minutes to hours vs strictly 5-60 minutes)
   • Association with headache (before, during, after, or independent)
   • Number of episodes (≥5 for VM)

2. Evaluate for specific brainstem symptoms:

   • Dysarthria, vertigo, tinnitus, hypacusis, diplopia, ataxia, decreased consciousness
   • At least 2 required for MBA diagnosis

3. Consider timing and progression:

   • VM symptoms can be variable in timing relative to headache
   • MBA symptoms typically precede headache and resolve within 60 minutes

4. Rule out other causes:

   • Obtain audiogram to help differentiate from Ménière's disease 1
   • Consider MRI to rule out posterior circulation ischemia
   • Evaluate for BPPV with positioning tests

5. Apply appropriate diagnostic criteria:

   • Barany criteria for VM
   • ICHD-3 criteria for MBA, with stricter interpretation recommended 6