What is vestibular migraine in a 30-year-old female patient with a history of intractable migraine?

What is Vestibular Migraine?

Vestibular migraine is a neurological disorder characterized by 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 in at least 50% of episodes, occurring in patients with current or previous history of migraine. 1

Diagnostic Criteria

For a definite diagnosis of vestibular migraine, patients must meet all of the following criteria:

• At least 5 episodes of moderate-to-severe vestibular symptoms lasting 5 minutes to 72 hours 1
• Current or previous history of migraine with or without aura according to International Classification of Headache Disorders (ICHD) criteria 1
• Migraine features present during at least 50% of vestibular episodes, including at least one of: one-sided location, pulsating quality, moderate-to-severe pain intensity, or aggravation by routine physical activity 1
• Symptoms not better accounted for by another vestibular or headache disorder 2

Vestibular symptoms are rated "moderate" when they interfere with but do not prohibit daily activities, and "severe" if daily activities cannot be continued 2, 1

Clinical Presentation

Vestibular Symptoms

The hallmark vestibular symptoms include:

• Spontaneous vertigo (sense of rotation or spinning) 2
• Positional vertigo triggered by head position changes or visual stimulation 1
• Unsteadiness and balance disturbance 1
• Motion sensitivity and extreme susceptibility to self and surround motion 3, 4

Episode Duration Patterns

Episode duration is highly variable and follows a characteristic distribution:

• 30% of patients experience episodes lasting minutes 2, 1
• 30% have attacks lasting hours 2, 1
• 30% have attacks over several days 2, 1
• 10% have attacks lasting only seconds, occurring repeatedly during head motion or visual stimulation 2, 1

Some patients may take up to four weeks to fully recover from an episode, though the core episode rarely exceeds 72 hours 2, 1

Accompanying Migraine Features

During vestibular episodes, patients commonly experience:

• Photophobia and phonophobia (sound-induced discomfort that is transient and bilateral) 2, 1, 3
• 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 2, 1
• Nausea and vomiting 3, 4
• Osmophobia (sensitivity to smells) 4

Importantly, episodes of vertigo are often but not always accompanied by headache, which can lead to misdiagnosis 5, 4

Auditory Symptoms and Differential Diagnosis

Auditory Manifestations

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

This contrasts with Ménière's disease, where unilateral fluctuating sensorineural hearing loss is a defining feature 2

Key Distinguishing Features

Phonophobia must be differentiated from recruitment, which is often unilateral and persistent, leading to enhanced perception and distortion of loud sounds in an ear with decreased hearing 2

Loss of consciousness is never a symptom of vestibular migraine and should prompt immediate evaluation for alternative diagnoses such as syncope or seizure 6, 7

Epidemiology and Clinical Context

Vestibular migraine is remarkably common:

• Affects 1-3% of the general population 3, 5
• Affects 10-30% of patients seeking treatment for dizziness 3
• Prevalence is 2.7% in population studies and 10% in outpatient clinics using Barany diagnostic criteria 2

It is now considered the most common neurologic cause of vertigo in adults 4

Special Considerations for Your Patient

In a 30-year-old female with a history of intractable migraine:

• Vestibular migraine often begins several years after typical migraine onset, and the delay between onset of headache and vertigo may be long 5
• Motion intolerance and susceptibility to motion sickness are common features 1, 6
• Mood disorders, particularly anxiety, are frequently found in vestibular migraine patients and may serve as a bridge to developing persistent postural-perceptual dizziness (PPPD) 8
• Recurrent episodes can affect emotions, sleep, and cognitive functioning to varying degrees, significantly lowering quality of life 8

Common Diagnostic Pitfalls

• Patients may use vague descriptions of "dizziness" rather than clearly describing vertigo (spinning), making diagnosis difficult 2
• Episodes occurring without concurrent headache can prompt misdiagnosis, as headache is not required in every episode 5, 4
• The condition remains underdiagnosed and undertreated despite published diagnostic criteria, as it is little known among medical communities 5
• Every patient with vertigo of unknown origin should be directly asked about past or present history of migraine, or migraine symptoms experienced during vertigo episodes 5