What are the key components of a physical exam for a vestibular migraine?

Physical Examination for Vestibular Migraine

The physical examination in vestibular migraine is typically normal between episodes, but should focus on identifying central versus peripheral vestibular pathology and ruling out other vestibular disorders through specific provocative maneuvers and neurologic assessment. 1

Key Examination Components

Neurologic Assessment to Exclude Central Pathology

The primary goal is distinguishing vestibular migraine from dangerous central causes of vertigo:

• Cranial nerve examination to identify abnormalities suggesting brainstem or cerebellar pathology (dysarthria, dysphagia, dysmetria, sensory/motor deficits, Horner's syndrome) 1
• Visual disturbance assessment beyond typical migraine aura 1
• Severe headache evaluation that may indicate intracranial pathology 1

Nystagmus Evaluation

Critical nystagmus patterns that suggest central pathology rather than vestibular migraine include:

• Downbeating nystagmus on Dix-Hallpike maneuver, particularly without torsional component 1
• Direction-changing nystagmus without changes in head position (periodic alternating nystagmus) 1
• Gaze-evoked nystagmus (beats to the right with right gaze, to the left with left gaze) 1
• Baseline nystagmus without provocative maneuvers 1

Interictal Neuro-Otologic Findings in Vestibular Migraine

Abnormal interictal examination findings occur in 42.7% of vestibular migraine patients, commonly including: 2

• Hyperventilation-induced nystagmus 2
• Head-shaking-induced nystagmus 2
• Vibration-induced nystagmus 2
• Positional nystagmus (non-BPPV pattern) 2

Balance Testing

• Sharpened Romberg test is the most commonly impaired balance test, abnormal in 16.9% of vestibular migraine patients 2
• Assessment for fall risk, particularly in patients with impaired mobility, CNS disorders, or lack of home support 1

Dix-Hallpike Maneuver

While primarily used to diagnose BPPV, this maneuver helps differentiate vestibular migraine from positional vertigo:

• Positive Dix-Hallpike with classic BPPV pattern (upbeating-torsional nystagmus with latency and fatigue) suggests BPPV rather than vestibular migraine 1
• Vestibular migraine may show atypical positional responses but should not demonstrate classic BPPV nystagmus 1

When Additional Testing is NOT Needed

Routine vestibular function testing and neuroimaging should NOT be obtained when the clinical diagnosis of vestibular migraine is clear based on Barany Society criteria (≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, migraine history, migrainous features during ≥50% of episodes) 1, 3, 4

• Vestibular testing adds little diagnostic value when clinical criteria are met and adds unnecessary cost and treatment delays 1, 3
• Normal vestibular test results do not rule out vestibular disorders 3

When Additional Testing IS Indicated

Order vestibular function testing or neuroimaging when: 1, 3

• Additional neurologic symptoms suggest central pathology (abnormal cranial nerves, visual disturbances, severe headache) 1
• Nystagmus patterns are atypical or suggest central pathology 1, 3
• Clinical presentation is unclear or diagnosis uncertain 1, 3
• Multiple concurrent vestibular disorders are suspected 1, 3
• Patient fails to respond to appropriate treatment 1

Common Pitfalls

• Missing central pathology: Always assess for brainstem/cerebellar signs, as 10% of cerebellar strokes can present similarly to peripheral vestibular processes 1
• Assuming normal exam rules out vestibular migraine: Physical examination and laboratory testing are usually normal in vestibular migraine but this does not exclude the diagnosis 5
• Over-testing clear diagnoses: When Barany criteria are met, additional testing is unnecessary and delays treatment 1, 3, 4