What are the symptoms of vestibular migraine?

Symptoms of Vestibular Migraine

Vestibular migraine presents with recurrent episodes of moderate-to-severe vestibular symptoms (vertigo, unsteadiness, balance disturbance, or motion sensitivity) lasting 5 minutes to 72 hours, accompanied by migraine features (headache, photophobia, phonophobia, or visual aura) in at least 50% of episodes. 1

Core Vestibular Symptoms

The primary vestibular manifestations include:

• Spontaneous vertigo (spinning sensation) occurring without provocation, reported in 57% of patients 2
• Unsteadiness (91% of patients) and balance disturbance (82% of patients) 2
• "Light-headedness" (77% of patients) 2
• Positional vertigo triggered by head position changes or visual stimulation 1, 3
• Head-motion dizziness and extreme sensitivity to self and surround motion 4, 3

These vestibular symptoms are rated moderate when they interfere with but do not prohibit daily activities, and severe if daily activities cannot be continued. 1

Episode Duration and Patterns

The temporal characteristics are highly variable:

• 30% of patients experience episodes lasting minutes 1
• 30% have attacks lasting hours 1
• 30% have attacks over several days 1
• 10% have attacks lasting only seconds, occurring repeatedly during head motion or visual stimulation 1

Important caveat: While the core episode rarely exceeds 72 hours, some patients may take up to four weeks to fully recover from an episode. 1

Migraine Features During Episodes

At least one of the following must occur with ≥50% of vestibular episodes:

Headache Characteristics (requiring ≥2 features):

• One-sided location 1
• Pulsating quality 1
• Moderate or severe pain intensity 1
• Aggravation by routine physical activity 1

Associated Symptoms:

• Photophobia (light sensitivity) and phonophobia (sound-induced discomfort) - common accompanying symptoms 1, 4, 5
• Visual aura characterized by bright scintillating lights, zigzag lines, or scotomas that expand over 5-20 minutes and last less than 60 minutes, often restricted to one hemifield 1, 6
• Nausea and vomiting 4, 3

Critical distinction: Phonophobia is transient and bilateral, unlike recruitment (unilateral and persistent enhanced perception of loud sounds in an ear with decreased hearing). 1

Temporal Relationship Between Symptoms

The migraine features may occur before, during, or after the vestibular symptoms. 1 However, vestibular symptoms and headache occur concomitantly in only 48% of patients. 2

Auditory Symptoms

While not required for diagnosis, auditory symptoms frequently accompany vestibular migraine:

• Transient auditory symptoms may occur and can mimic Ménière's disease 1, 3
• When present, hearing complaints are typically bilateral and related to sound processing rather than true hearing loss 6
• Hearing loss, if present, is mild or absent and stable over time (unlike the fluctuating hearing loss in Ménière's disease) 1

Additional Clinical Features

• Motion intolerance and susceptibility to motion sickness 1, 6, 7
• Osmophobia (sensitivity to smells) 3
• Mood disorders, particularly anxiety, are often found in vestibular migraine patients 3

Evolution of Symptoms

The natural history shows heterogeneity:

• 47% of patients have chronic symptoms from onset 2
• 21% have episodic symptoms 2
• 32% evolve from episodic to chronic, with an average duration of 7 years required for this evolution 2
• Migraine onset typically precedes vestibular symptoms by a mean of 8 years 2

Critical Red Flag

Loss of consciousness is NEVER a symptom of vestibular migraine and should prompt immediate evaluation for alternative diagnoses such as syncope or seizure. 1, 6

Diagnostic Requirements

For definite vestibular migraine diagnosis, patients must have:

• At least 5 episodes meeting the vestibular symptom criteria 1
• Current or previous history of migraine with or without aura according to ICHD criteria 1
• Symptoms not better accounted for by another vestibular or headache disorder 1