What is vestibular migraine?

Vestibular migraine (also referred to as migrainous vertigo, migraine-related dizziness, vestibular migraine or migraine with prominent vertigo) is a type of migraine where people experience a combination of vertigo, dizziness or balance problems with other migraine symptoms.

Symptoms

Migraine is usually associated with a range of typical symptoms alongside headache including:

• feeling sick (nausea) and/or being sick (vomiting)
• sensitivity to light (photophobia),
• sensitivity to sound (phonophobia)
• sensitivity to movement (for some people exercise can make their headache worse).

These symptoms all feature in the criteria used to diagnose migraine.

However, there are other migraine symptoms that are not included in the criteria used to make a diagnosis (despite them being common). These include

• a sensation of movement (vertigo)
• sensitivity to smells (osmophobia)
• light causing pain not just sensitivity (photic allodynia)
• sensitivity to touch on the head or face (cranial allodynia).

It is possible for people to have vertigo attacks without any headache. However, for vestibular migraine to be diagnosed migraine headache should be present at some point.

What is vertigo?

Vertigo can be defined as a sensation of movement. For some people it is described as a spinning dizziness (external vertigo), for others it’s a sensation of swaying (internal vertigo).

The best way to work out which one you may be experiencing is whether it is the world that is moving, or is it yourself?

Vertigo can be spontaneous and can also be triggered by position (standing up or lying down), head movement or visually-induced.

Vertigo can be very disabling and very prominent in migraine. This is why vestibular migraine has its own category in the International Classification of Headache Disorders (ICHD-3).

Diagnosis

Many people with symptoms of vestibular migraine are seen by ear, nose and throat (ENT) specialists and neuro-otologists (experts in dizziness and balance disorders). People may be more likely to see these specialists (rather than a general neurologist or headache specialist) when they have vertigo symptoms without any headache.

According to the ICHD-3 the diagnosis of vestibular migraine needs:

• at least five episodes
• a present or past history of migraine
• vestibular symptoms (vertigo or dizziness) lasting between five minutes and 72 hours
• migraine headache or other migraine associated symptoms in at least half of the episodes.

As shown in the diagnostic criteria, the length of the vertigo attacks or ‘dizzy spells’ may be different for different people. For many people these would last for hours but others report their vertigo attacks could last for minutes or days and a minority reports that they last for seconds.

Ruling out other vestibular disorders may be needed. This is where management by a range of professionals, such as GPs, neurologists and neuro-otologists or ENT specialists is recommended.

The vestibular function tests (these assess the inner ear balance organs and identify if one or both are working properly) should show that vestibular function is within normal limits, in people with suspected vestibular migraine. Abnormal results in vestibular function tests should lead to the suspicion of other vestibular disorders such as Meniere’s disease.

Treatment options for vestibular migraine

Treatment of vestibular migraine is similar to that of other types of migraine, with special focus on standard migraine preventive medications such as amitriptyline, propranolol, candesartan and flunarizine. Flunarizine is not available through the GP but is available from headache clinics and often a preventive of choice in this setting. Greater Occipital Nerve blocks may also be used in this setting.

The acute treatment of the headache attacks is the same as the usually recommended for migraine. This is based on migraine-specific medications, triptans or non-specific such as non-steroidal anti-inflammatory drugs (naproxen, ibuprofen, etc) and acetaminophen (Paracetamol). Opioids should be avoided. For the vertigo attacks a short course of prochlorperazine may be beneficial as a potential vestibular sedative, and antiemetic medications such as ondansetron and domperidone may also be useful.