Diagnostic Criteria for Vestibular Migraine
The diagnosis of vestibular migraine requires at least 5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, accompanied by migraine features in at least 50% of episodes, with current or previous history of migraine and exclusion of other vestibular disorders. 1, 2
Core Diagnostic Requirements
The definite diagnosis of vestibular migraine mandates all of the following criteria:
- ≥5 episodes of vestibular symptoms including vertigo, unsteadiness, balance disturbance, or motion sensitivity 1, 2
- Episode duration of 5 minutes to 72 hours per attack 1, 2
- Current or previous history of migraine with or without aura according to International Headache Society criteria 2
- Migraine features present during ≥50% of vestibular episodes, including at least one of the following: 2
- One-sided headache location
- Pulsating quality
- Moderate or severe pain intensity
- Aggravation by routine physical activity
- Photophobia and phonophobia commonly accompany episodes 2
- Other vestibular or headache disorders ruled out by appropriate investigations 1, 2
Vestibular Symptom Severity Classification
- Moderate vestibular symptoms interfere with but do not prohibit daily activities 2
- Severe vestibular symptoms prevent continuation of daily activities 2
- Positional vertigo may be triggered by head position changes or visual stimulation 2
Episode Duration Patterns
The temporal patterns of vestibular migraine vary considerably:
- 30% of patients experience episodes lasting minutes 2
- 30% have attacks lasting hours 2
- 30% have attacks over several days 2
- 10% have attacks lasting only seconds, occurring repeatedly during head motion or visual stimulation 2
- Some patients may require up to four weeks to fully recover from an episode 2
Associated Migraine Features
Visual aura characteristics when present:
- Bright scintillating lights, zigzag lines, or scotomas 2
- Expand over 5-20 minutes and last less than 60 minutes 2
- Often restricted to one hemifield 2
Auditory Symptoms (Not Required for Diagnosis)
While not part of the formal diagnostic criteria, auditory symptoms may occur:
- Transient auditory symptoms can mimic Ménière's disease 2
- Hearing complaints are typically bilateral and related to sound processing rather than true hearing loss 2
- Hearing loss, if present, is mild or absent and stable over time (unlike the fluctuating hearing loss in Ménière's disease) 2
- Tinnitus may occur but is typically less prominent than in Ménière's disease 1
- 35% of Ménière's disease patients also meet criteria for vestibular migraine 1
Additional Clinical Features
- Motion intolerance and susceptibility to motion sickness are common 2
- Loss of consciousness is never a symptom of vestibular migraine and should prompt immediate evaluation for alternative diagnoses 2
Critical Diagnostic Pitfalls to Avoid
Distinguishing vestibular migraine from other vestibular disorders is essential:
- Ménière's disease can be distinguished by documented low-to-mid-frequency sensorineural hearing loss on audiometry and longer duration of vertigo attacks (20 minutes to 12 hours) 1
- Benign paroxysmal positional vertigo (BPPV) lacks the necessary migraine/headache components and has characteristic nystagmus patterns on Dix-Hallpike maneuver 3
- Central causes (stroke, multiple sclerosis) must be ruled out, particularly if nystagmus findings suggest neurological causes such as down-beating nystagmus, direction-changing nystagmus without head position changes, or baseline nystagmus without provocative maneuvers 3, 1
- Failure to respond to conservative management should raise concern that the underlying diagnosis may not be vestibular migraine 3