Definition and Overview
Vestibular migraine (VM) is a condition in which recurrent vestibular symptoms occur in patients who meet the clinical criteria for migraine [1]. Diagnostic criteria were jointly established by the International Headache Society (IHS) and the Barany Society [1], and it is one of the most common causes of recurrent vertigo.
Approximately 7-11% of dizziness clinic patients are diagnosed with vestibular migraine, and approximately 1% of the general population has the condition [4]. It is approximately 1.5-5 times more common in women than men, primarily occurring in the 30s to 50s [4]. Vestibular symptoms are reported to accompany approximately 10-36% of migraine patients [2].
Diagnostic Criteria
The criteria for definite vestibular migraine (definite VM) according to the 2012 IHS-Barany Society joint diagnostic criteria are as follows [1].
A. Current or past history of migraine (with or without aura) according to ICHD criteria. B. Five or more episodes of moderate to severe vestibular symptoms lasting 5 minutes to 72 hours. C. At least one of the following migraine features accompanying at least half of the vestibular episodes: migrainous headache, photophobia, phonophobia, visual aura. D. Not better accounted for by another vestibular diagnosis or ICHD diagnosis.
Probable vestibular migraine (probable VM) partially meets the above criteria but does not fulfill the definite criteria.
Characteristics of Vestibular Symptoms
Vestibular symptoms in vestibular migraine are diverse [2]. Spontaneous vertigo involves dizziness with a sensation of rotation or linear motion. Positional vertigo occurs with head position changes and requires differentiation from BPPV. Head motion-induced dizziness worsens with head movements. Visually induced vertigo occurs in the presence of moving objects or complex visual environments. Postural instability and balance impairment are also included.
The duration of vestibular symptoms ranges from less than 5 minutes to 72 hours, with minutes to hours being most common [1].
Pathogenesis
The exact mechanism of vestibular migraine has not been fully elucidated, but the neural connections between migraine pathophysiology and the vestibular system are understood to be central.
Cortical spreading depression (CSD) may involve vestibular cortical areas. CGRP (calcitonin gene-related peptide), a key neurotransmitter in migraine, is also known to act on the vestibular nuclei and inner ear [4]. Through the trigemino-vestibular connection, trigeminal activation appears to influence vestibular signaling [4].
The serotonin system is also involved. Various serotonin receptors are expressed in the vestibular nuclei, and serotonin changes in migraine may trigger vestibular symptoms [2].
Differentiation from Meniere's Disease
Both vestibular migraine and Meniere's disease present with recurrent vertigo attacks, making differentiation important [4].
The characteristic findings of Meniere's disease are the triad of unilateral sensorineural hearing loss (particularly low-frequency), tinnitus, and aural fullness. Vertigo typically lasts tens of minutes to several hours. In contrast, vestibular migraine is accompanied by migraine symptoms, with absent or mild hearing abnormalities. However, the two conditions can coexist, complicating differentiation.
Audiometry, vestibular evoked myogenic potentials (VEMP), video head impulse test (vHIT), and caloric testing aid in differentiation.
Treatment
Acute Attack Treatment
Triptans such as sumatriptan may be effective for both headache and vertigo during attacks [5]. Antiemetics (metoclopramide) and vestibular suppressants (diazepam, meclizine) are used for acute symptom relief. Rest and minimizing visual stimulation during attacks is advised.
Preventive Treatment
Preventive treatment is initiated when attacks are frequent (2 or more per month), severe, or cause significant functional impairment. Migraine preventive medications including topiramate, valproic acid, amitriptyline, and beta-blockers (propranolol, metoprolol) are also effective for vestibular migraine [5]. CGRP-targeting monoclonal antibodies (erenumab, galcanezumab) have also shown reported efficacy in vestibular migraine prevention.
Non-Pharmacological Treatment
Vestibular rehabilitation therapy helps improve postural instability and balance impairment between attacks. Lifestyle management (regular sleep, regular meals, caffeine and alcohol restriction, stress management) contributes to reducing attack frequency.