Vestibular migraine or migraine with prominent vertigo
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.
Migraine is usually associated with a range of typical symptoms alongside headache including nausea and/or vomiting, sensitivity to light (photophobia), sensitivity to sound (phonophobia) and a 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 vertigo, sensitivity to smells (osmophobia), light causing pain not just sensitivity (photic allodynia) and sensitivity to touch on the head or face (cranial allodynia).
What is vertigo?
Vertigo can be defined as a sensation of motion. 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).
The symptoms of vestibular migraine are vertigo or dizziness (vestibular symptoms) alongside other migraine symptoms such as headache, nausea, sensitivity to light and sound and aura (visual disturbances, sensory disturbances, motor disturbances).
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.
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
- the concurrence of 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 (in people with suspected vestibular migraine) is within normal limits Abnormal results in vestibular function tests should lead to the suspicion of other vestibular disorders such as Meniere’s disease.
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, 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 prochlorperarzine may be beneficial as a potential vestibular sedative, and antiemetic medications such as ondansetron and domperidone may also be useful.
How The Migraine Trust can help
If you have questions about vestibular migraine you can contact our Information service via our online form. Alternatively, you can call us on 0203 9510 150 (from 10am to 4pm on Tuesdays and Thursdays)
Content provided by Dr David Moreno-Ajona, Basic and Clinical Neurosciences, Institute of Psychiatry, Psychology and Neuroscience King’s College London, United Kingdom and NIHR-Wellcome Trust King’s Clinical Research Facility/SLaM Biomedical Research Centre, King’s College Hospital, London, United Kingdom.
Date: April 2020
Date of next review: April 2023