What is vestibular migraine?

Vestibular Migraine: Definition and Diagnostic Criteria

Vestibular migraine is a common neurological condition characterized by recurrent episodes of vestibular symptoms of moderate to severe intensity, lasting 5 minutes to 72 hours, associated with migraine features, and not better explained by another vestibular or headache disorder. 1

Diagnostic Criteria

According to the Barany Society diagnostic criteria, vestibular migraine requires:

• At least 5 episodes of vestibular symptoms of moderate to severe intensity 1
• Duration of episodes ranging from 5 minutes to 72 hours 1
• Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders 1
• One or more migraine features during at least 50% of vestibular episodes:
  • Headache with at least two characteristics: one-sided location, pulsating quality, moderate/severe intensity, aggravation by physical activity 1
  • Photophobia and phonophobia 1
  • Visual aura 1
• Exclusion of other vestibular disorders 1

Epidemiology and Significance

• Lifetime prevalence of 3.2% in the general population 1
• Accounts for approximately 14% of all vertigo cases 1
• More common in women than men 2
• Can begin at any age, with highest prevalence in young adults and between ages 60-70 2
• Considered the most common cause of spontaneous recurrent episodic vertigo 2, 3

Clinical Presentation

Vestibular symptoms in vestibular migraine may include:

• Spontaneous vertigo 1, 2
• Positional vertigo 2, 3
• Head-motion dizziness 3
• Triggered vertigo 3

Important characteristics:

• Vestibular symptoms are rated as "moderate" when they interfere with but do not prohibit daily activities, and "severe" if daily activities cannot be continued 1
• Duration of episodes is highly variable:
  • About 30% have episodes lasting minutes 1
  • 30% have attacks lasting hours 1
  • 30% have attacks lasting several days 1
  • 10% have brief attacks lasting seconds that tend to occur repeatedly 1
• Episodes may or may not be accompanied by headache 3
• Associated symptoms may include auditory symptoms that can mimic Ménière's disease 3

Differential Diagnosis

Vestibular migraine must be distinguished from:

• Benign paroxysmal positional vertigo (BPPV) 1
• Ménière's disease 1, 3
• Brainstem and cerebellar stroke 1
• Transient ischemic attacks 1
• Intracranial tumors 1
• Multiple sclerosis 1
• Episodic ataxia type 2 3

Clinical Pitfalls and Challenges

• About one-third of patients present with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms, making diagnosis challenging 2
• Vestibular migraine can mimic or co-exist with other vestibular disorders 4
• The condition remains underdiagnosed despite being common 3
• Patients may have comorbid mood disorders, particularly anxiety 3
• Patients may have abnormal neuro-otologic findings between attacks 3

Treatment Approaches

While high-quality evidence is limited, treatment options include:

• Acute/abortive treatments:

  • Triptans are typically first-line for acute attacks 5, 3
  • Vestibular suppressants and antiemetic agents may be considered 3
  • Neurostimulating devices can be an option 5

• Preventive treatments:

  • Flunarizine appears to be the first-line preventive option based on randomized clinical trials 5
  • Second-line preventives include propranolol, topiramate, venlafaxine, and valproic acid 5
  • Non-pharmacological options include vestibular rehabilitation 5, 6

Understanding vestibular migraine requires recognizing its heterogeneous presentation and relationship between vestibular symptoms and migrainous features, as well as distinguishing it from other causes of vertigo 3.