What are the diagnostic criteria for migraines with vertigo (benign paroxysmal positional vertigo)?

From the Guidelines

Diagnosing migraine with vertigo (vestibular migraine) involves a careful evaluation of symptoms and ruling out other conditions, with the diagnosis requiring recurrent episodes of vertigo lasting minutes to hours, a history of migraines, and at least half of the vertigo episodes being associated with migraine features such as headache, visual aura, sensitivity to light or sound, or nausea, as outlined in the Barany Diagnostic Criteria for Vestibular Migraine 1.

Key Diagnostic Criteria

The diagnosis of vestibular migraine is based on the following criteria:

• At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
• Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
• One or more migraine features with at least 50% of the vestibular episodes, such as headache, visual aura, sensitivity to light or sound, or nausea
• Not better accounted for by another vestibular or ICHD diagnosis

Diagnostic Approach

A healthcare provider will typically diagnose vestibular migraine based on a detailed medical history, focusing on the pattern of vertigo episodes and their relationship to migraine symptoms. Physical examination, including neurological tests, helps rule out other causes of vertigo. Diagnostic tests may include:

• Audiometry to assess hearing
• Videonystagmography to evaluate eye movements and inner ear function
• Brain imaging like MRI to exclude structural abnormalities
• Vestibular function test to assess balance system function

Importance of Symptom Diary

Keeping a symptom diary documenting the frequency, duration, and characteristics of vertigo episodes along with any accompanying migraine symptoms can be extremely helpful for diagnosis. The diagnosis is often made after excluding other potential causes of vertigo such as Meniere's disease, benign paroxysmal positional vertigo, or vestibular neuritis, as discussed in various clinical practice guidelines 1.

From the Research

Diagnosing Migraine with Vertigo

To diagnose migraine with vertigo, several factors and symptoms must be considered:

• The patient's history of migraine and vertigo episodes, including triggers and timing 2, 3
• The presence of vestibular symptoms such as vertigo, disequilibrium, or imbalance, which are common in vestibular migraine (VM) 4
• The absence of hearing loss, which can help distinguish VM from other disorders like Meniere's disease 4
• The results of physical examinations, such as the HINTS (head-impulse, nystagmus, test of skew) examination, which can help determine whether the etiology is peripheral or central 5

Clinical Presentation and Epidemiology

• Migraine with vertigo can present with a spectrum of clinical symptoms, including episodic vertigo, fluctuating or daily symptoms, and exacerbation with activity and head movements 4, 2
• The epidemiological link between migraine and vestibular symptoms suggests shared pathogenetic mechanisms 2
• The clinical presentation can be similar to other disorders, making diagnosis challenging 5, 3

Diagnostic Criteria and Assessment

• The use of standardized assessment criteria and tools, such as a structured diagnostic interview, can help identify migrainous vertigo and develop a pathophysiological model 2
• The application of published criteria for the diagnosis of migrainous vertigo allows for the development of a standardized assessment interview 2
• A thorough physical examination, including orthostatic blood pressure measurement, a full cardiac and neurologic examination, assessment for nystagmus, and the Dix-Hallpike maneuver, can help determine the etiology of the symptoms 5

Differential Diagnosis and Management

• Differential diagnosis should include other disorders that can cause vertigo, such as benign paroxysmal positional vertigo, Meniere's disease, and vestibular neuritis 4, 5
• Management of migraine with vertigo may include migraine-specific medications, such as triptans, and preventive treatment, such as propranolol, venlafaxine, topiramate, and amitriptyline 4
• Vestibular rehabilitation may also be helpful in managing symptoms 4