Vestibular migraine (VM) or migraine associated vertigo (MAV) is defined as a migraine variant presenting with additional vestibular symptoms in addition to typical migraine symptoms. It is estimated that around 40% of migraineurs have a vestibular component to their symptoms. VM is the second most common cause of vertigo and almost as prevalent as high blood pressure in adults. VM can occur years after a previous migraine diagnosis. It is most commonly diagnosed in women ages 20-40 and in men at a slightly older age. Even with increased understanding and awareness of VM in recent years, nearly 50% of patients with VM go undiagnosed or are mismanaged. It is mostly a diagnosis of exclusion, and other vestibular disorders should be ruled out as a contributing factor to the patient’s symptoms. Anxiety related dizziness disorders can also influence VM diagnosis.
According to the Vestibular Disorders Association, migraine is typically categorized by: “unilateral onset of head pain, severe progression of intensity of head pain, throbbing or pounding, and interference with the person’s routine activities”. Migraines may also include photophobia (light sensitivity) or phonophobia (sound sensitivity). Auditory symptoms can include: hearing loss, tinnitus, or aural pressure. Hearing loss does not fluctuate with VM symptoms, but remains stable, unlike Meniere’s Disease. Vestibular symptoms may include: positionally provoked vertigo, spontaneous vertigo, visually-induced vertigo, head-motion induced vertigo, loss of balance, ataxia, spatial disorientation, and nausea or emesis with dizziness. Dizziness may occur prior to, during, after, or independent of a typically defined migraine event, which aids to the complexity of its diagnosis. VM can often be masked by positionally provoked vertigo leading to an often misdiagnosis of BPPV (benign positional paroxysmal vertigo).
A clinical evaluation with a team of medical experts is valuable in helping diagnose VM. A combination approach of medical management, vestibular testing, clinical evaluation, and rehabilitation can be used to provide the most complete care plan. Specialties that may be involved in the diagnosis and treatment team include: neurology, otolaryngology, vestibular audiology, and/or vestibular rehabilitation therapists. This team will utilize their comprehensive testing to further evaluate systems that could be involved in the symptoms.
Treatments may include investigating triggers to VM events such as foods, hormone fluctuations, weather changes, stress, sleep disturbance, etc. similar to those in traditional migraine diagnosis. Often times diet modifications and medications may be used to prevent the dizziness component of migraines. Vestibular rehabilitation benefits are well documented in the research literature to help reduce symptoms and restore vestibular function. Prescribed medications should be initiated before starting rehabilitation therapy and may allow for increased tolerance in vestibular exercises. Rehabilitation starts off easy and progresses to more difficult tasks to increase the patient’s abilities, but not induce another migraine event. In combination, medication therapy and vestibular rehabilitation therapy can provide relief for patients with vestibular migraines. If you or a loved one have experienced similar symptoms or concerns, contact a vestibular provider and/or otolaryngologist to initiate a comprehensive evaluation and decide the best treatment plan.
Bisdorff, A. (2011). Management of vestibular migraine. Therapeutic Advances in Neurologic Disorders, 4(3): 183-191.
O’Connell Ferster, A., et al. (2017). The clinical manifestations of vestibular migraine: A review. Auria Nasus Larynx, 44: 249-252.
Vestibular Migraine. (2019, August 2). Vestibular Disorders Association. Retrieved December 23, 2019, from https://vestibular.org/migraine-associated-vertigo-mav.