What is the differential diagnosis and treatment for patients presenting with migraine and vertigo?

Differential Diagnosis for Migraine and Vertigo

When a patient presents with both migraine and vertigo, vestibular migraine should be your primary diagnostic consideration, followed by Ménière's disease, BPPV, and central causes requiring urgent neuroimaging. 1

Primary Differential Diagnoses

Vestibular Migraine (Most Common)

• Vestibular migraine accounts for approximately 14% of all vertigo cases and represents the most common cause of spontaneous episodic vertigo in patients with migraine history 2, 3
• Diagnostic criteria require: episodic vestibular symptoms lasting 5 minutes to 72 hours, current or history of migraine, migraine symptoms (photophobia, phonophobia, visual aura) during at least 50% of dizzy episodes, and exclusion of other causes 4, 3
• Episodes can be short (<15 minutes) or prolonged (>24 hours), with visual auras commonly described before, during, or after attacks 1
• Motion intolerance and light sensitivity are characteristic triggers that help distinguish this from other causes 1
• Hearing loss is typically mild, absent, or stable over time—not fluctuating like Ménière's disease 1

Ménière's Disease

• Characterized by the classic triad: episodic vertigo lasting hours, fluctuating sensorineural hearing loss, tinnitus, and aural fullness 1
• Accounts for 10% of vertigo cases in general practice and up to 43% in specialty settings 2
• The key distinguishing feature from vestibular migraine is fluctuating hearing loss that worsens over time, whereas vestibular migraine has stable or absent hearing loss 1
• Can overlap with vestibular migraine in the same patient, creating diagnostic complexity 1

Benign Paroxysmal Positional Vertigo (BPPV)

• The most common cause of peripheral vertigo overall (42% of cases), characterized by brief episodes (<1 minute) triggered by specific head position changes 1, 2
• Diagnosed with Dix-Hallpike maneuver showing characteristic nystagmus with latency, fatigability, and torsional component 2, 3
• Can coexist with vestibular migraine or Ménière's disease 2

Central Causes (Urgent Evaluation Required)

Vertebrobasilar Insufficiency/Stroke

• Approximately 25% of patients presenting with acute vestibular syndrome have cerebrovascular disease, rising to 75% in high vascular risk cohorts 2, 3
• Isolated transient vertigo lasting <30 minutes without hearing loss may precede stroke by weeks to months 2, 4
• Severe postural instability with falling is the hallmark distinguishing feature 2, 4

Posterior Fossa Lesions

• Brainstem and cerebellar stroke account for approximately 3% of vertigo cases, though 10% of cerebellar strokes can mimic peripheral vestibular disorders 2, 4
• Multiple sclerosis and demyelinating diseases can present with vertigo 4
• Posterior fossa tumors including vestibular schwannomas must be excluded 1

Other Peripheral Causes

• Vestibular neuritis (41% of peripheral vertigo cases): acute continuous vertigo lasting days without hearing loss 2, 3
• Labyrinthitis: vertigo with associated hearing loss 2
• Superior canal dehiscence syndrome 2
• Perilymphatic fistula 1

Critical Red Flags Requiring Immediate Neuroimaging

Any of the following demand urgent MRI (not CT) of the posterior fossa: 2, 3

• Severe postural instability with falling 2, 4
• Direction-changing nystagmus without head position changes 2, 4
• Purely vertical nystagmus (upbeating or downbeating) without torsional component 2, 3
• Downbeating nystagmus on Dix-Hallpike maneuver 2, 3
• Baseline nystagmus present without provocative maneuvers 2, 4
• Nystagmus that does not fatigue with repeated testing and is not suppressed by visual fixation 2, 4
• New-onset severe headache with vertigo 2
• Additional neurological symptoms: dysarthria, dysmetria, dysphagia, diplopia, sensory/motor deficits, Horner's syndrome, limb weakness, truncal/gait ataxia 2, 4
• Failure to respond to appropriate peripheral vertigo treatments 2, 4

Diagnostic Approach Algorithm

Step 1: Classify by Timing and Triggers 2, 3

Triggered Episodic (<1 minute, position-dependent):

• Primary consideration: BPPV
• Perform Dix-Hallpike and supine roll test 3

Spontaneous Episodic (minutes to hours, no triggers):

• Primary considerations: Vestibular migraine, Ménière's disease, vertebrobasilar TIA
• Assess for migraine history and symptoms during episodes 2, 3
• Evaluate for fluctuating hearing loss, tinnitus, aural fullness 1

Acute Vestibular Syndrome (continuous days to weeks):

• Primary considerations: Vestibular neuritis, labyrinthitis, posterior circulation stroke
• Immediate MRI if any red flags present 3

Step 2: Nystagmus Examination 2, 3

Peripheral pattern (reassuring):

• Horizontal with rotatory component
• Unidirectional
• Suppressed by visual fixation
• Fatigable with repeated testing
• Brief latency before onset

Central pattern (concerning):

• Pure vertical without torsional component
• Direction-changing without head position changes
• Not suppressed by visual fixation
• Persistent without modification on repositioning

Step 3: Assess Migraine Features 1

• Inquire about current or past migraine history, family history of migraine, motion intolerance
• Determine if photophobia, phonophobia, or visual aura occur during at least 50% of vertigo episodes
• Note that in migraine, "hearing loss" may represent difficulty processing sound rather than true hearing loss, and auditory complaints are often bilateral 1

Step 4: Evaluate Hearing 1

• Fluctuating hearing loss that worsens over time suggests Ménière's disease
• Stable or absent hearing loss suggests vestibular migraine
• Acute hearing loss with vertigo suggests labyrinthitis

Treatment Approach

Vestibular Migraine

• Migraine prophylactic treatment shows 69.3% satisfactory control of symptoms and 81.8% achieve at least 50% reduction in vertiginous episode frequency 5
• Prophylactic options include propranolol (effective for migraine prophylaxis per FDA labeling), tricyclic antidepressants, calcium channel blockers, or topiramate 6, 7, 5
• Dietary modifications, lifestyle adaptations, and trigger avoidance 7
• Acute treatment with standard migraine therapies during episodes 8, 7
• Complete or substantial control of vestibular symptoms achieved in 92% of patients with episodic vertigo, 89% with positional vertigo, and 86% with non-vertiginous dizziness using individualized migraine management 7

BPPV

• Canalith repositioning procedures (Epley maneuver for posterior canal, Lempert maneuver for lateral canal) with approximately 80% success rate 3
• Do NOT use vestibular suppressant medications—they do not address the underlying pathophysiology 3

Vestibular Neuritis

• Oral corticosteroids within 3 days of onset 3
• Vestibular suppressants (meclizine 25-100mg daily) for maximum 3 days only to avoid impeding central compensation 3

Ménière's Disease

• Dietary sodium restriction, diuretics, and vestibular rehabilitation per Ménière's disease guidelines 1

Common Pitfalls to Avoid

• Overlooking vestibular migraine as a diagnosis—it is under-recognized despite being extremely common in patients with both migraine and vertigo 1, 9
• Failing to distinguish between fluctuating hearing loss (Ménière's) versus stable/absent hearing loss (vestibular migraine) 1
• Missing subtle neurological signs indicating central pathology 2
• Using vestibular suppressants beyond 3 days, which impedes central vestibular compensation 3
• Treating BPPV with medications instead of canalith repositioning procedures 3
• Assuming all positional vertigo is BPPV without considering that vestibular migraine can also have positional triggers 1
• Not recognizing that multiple concurrent vestibular disorders can coexist in the same patient 2
• Performing routine neuroimaging in diagnosed BPPV without red flags (unnecessary and costly) 2
• Relying on CT instead of MRI when central pathology is suspected—MRI is the preferred imaging modality for posterior fossa evaluation 3