Symptoms of Vestibular Migraine
Vestibular migraine presents with episodic vestibular symptoms lasting 5 minutes to 72 hours, including spontaneous vertigo, positional vertigo, movement-provoked dysequilibrium, and head-motion dizziness, often accompanied by migrainous features such as photophobia, phonophobia, and visual aura. 1
Core Vestibular Symptoms
The vestibular manifestations are highly variable and may include:
- Spontaneous vertigo (spinning sensation without provocation) lasting anywhere from seconds to days 1, 2
- Positional vertigo triggered by head position changes 3
- Movement-provoked dysequilibrium and chronic imbalance 4, 5
- Head-motion intolerance with space and motion discomfort 5
- Lightheadedness and unsteadiness 4
Approximately one-third of patients experience monosymptomatic attacks of vertigo without concurrent headache, making diagnosis challenging 2. The duration of episodes is diagnostically important: vestibular migraine typically causes symptoms lasting 5 minutes to 72 hours, which helps distinguish it from Ménière's disease (20 minutes to 12 hours) 1.
Migrainous Features
During or surrounding vestibular episodes, patients commonly report:
- Photophobia (light sensitivity) 6, 3
- Phonophobia (sound sensitivity) 3
- Osmophobia (sensitivity to odors) 3
- Visual auras occurring before, during, or after attacks 6, 3
- Headache (though notably absent in about one-third of attacks) 2
The presence of motion intolerance and light sensitivities combined with visual auras helps differentiate vestibular migraine from Ménière's disease 6.
Auditory Symptoms
While vestibular migraine can present with auditory complaints, these differ from Ménière's disease:
- Bilateral auditory symptoms are more common than unilateral 6
- Perception of difficulty processing sound rather than true hearing loss 6
- Mild or absent hearing loss that remains stable over time (unlike the fluctuating, progressive low-to-mid-frequency sensorineural hearing loss seen in Ménière's disease) 6, 1
- Tinnitus may occur but is typically less prominent than in Ménière's disease 6
Physical Examination Findings
During acute attacks, objective findings include:
- Spontaneous or positional nystagmus in most patients 2
- Minor ocular motor and vestibular deficits even between attacks 2
- Directional preponderance on rotational testing 5
- Unilateral reduced caloric responsiveness 5
- Vestibular system dysfunction patterns on posturography 5
Critical red flags suggesting central pathology rather than vestibular migraine include downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, gaze-evoked nystagmus, and baseline nystagmus without provocation 7.
Interictal Symptoms
Between attacks, patients may experience:
- Persistent dizziness or chronic imbalance 3
- Isolated paroxysmal vestibular symptoms 3
- Mood disorders, particularly anxiety, which are frequently comorbid 3
Epidemiology and Triggers
- Women are significantly more affected than men 2
- Lifetime prevalence is 3.2%, accounting for up to 14% of vertigo cases and representing the most common cause of spontaneous recurrent episodic vertigo 1, 2
- Peak prevalence occurs in young adults and between ages 60-70 2
- Common triggers include stress, poor diet, nicotine, irregular sleep patterns, excessive caffeine, and alcohol 1, 4
Diagnostic Criteria
The Barany Society criteria require:
- ≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours 1, 7
- History of migraine (current or past) 1
- Migrainous features during ≥50% of episodes (headache, photophobia, phonophobia, or visual aura) 1, 7
When these criteria are clearly met and examination shows no central pathology signs, routine vestibular function testing and neuroimaging are not needed 7.
Common Diagnostic Pitfalls
- Missing central pathology by failing to assess for brainstem/cerebellar signs, as 10% of cerebellar strokes can mimic peripheral vestibular processes 7
- Overlooking vestibular migraine in patients without headache during attacks 2
- Confusing with Ménière's disease, particularly since 35% of Ménière's patients also meet criteria for vestibular migraine 1
- Dismissing bilateral auditory symptoms as non-vestibular when they may represent migraine-related auditory processing difficulties 6