Vestibular Migraine

Occurring in 30-50% of patients with migraine, vestibular migraine is characterized by symptoms of dizziness and vertigo. It is a somewhat underdiagnosed disorder — many areas of the brain play a role in balance and perception, resulting in slightly varied symptoms of vestibular migraine in different individuals. 

What Causes It?

Similar to other types of migraine syndromes, vestibular migraine tends to be heritable. Women experience this condition more than men, and their symptoms may worsen around menstruation. 

Clinicians often see people display symptoms of dizziness and vertigo if they already get migraines, or have a family history of migraine or motion sickness. Certain migraine triggers might also be responsible, including changes in sleep patterns, certain foods like chocolate, aged cheese and red wine, or food additives like MSG.

Possibly involved in, or affected during, a vestibular migraine episode are:

  • Gravity receptors in the inner ear known as otolith organs. Research notes that their signals to the brain may become distorted in people with vestibular migraine.
  • The cerebellum, located at the back of the brain and involved in balance and coordination.
  • Insula, part of the cerebral cortex known to include vestibular information processing among its many functions.

What Are the Symptoms?

Vestibular migraine can typically exhibit common migraine symptoms such as severe, throbbing headache, usually on one side of the head; nausea and vomiting; and sensitivity to light, smell, and noise. 

But people with vestibular migraine will experience additional symptoms even more prominent and debilitating than head pain, including: 

  • Vertigo (dizziness), typically lasting minutes to hours, and occasionally days
  • Unsteadiness and loss of balance, as if they’d been “pushed”
  • Sensitivity to motion
  • A feeling of being displaced in space, known as Alice in Wonderland Syndrome

How Is It Diagnosed?

Most people with vestibular migraine do not have vestibular symptoms at the same time as head pain, so onset of dizziness alone can make vestibular migraine challenging to diagnose. A number of other conditions can behave like it — and may even co-exist with it — including benign paroxysmal positional vertigo (BPPV), Méniére’s disease, and transient ischemic attack (“mini-stroke”). 

A healthcare professional may order testing to rule out these other disorders. They will also consider the patient’s migraine history and the repetitiveness, severity, and length of their vertigo episodes, and will note if other migraine symptoms have been known to occur simultaneously with the vertigo.

How Is It Treated?

Use of standard migraine treatments, such as NSAIDs, triptans, and anti-CGRP medications, may decrease migraine activity in general, improving all symptoms including vestibular activity.  Some studies show that drugs typically used for vertigo may help to alleviate vestibular migraine. Drugs such as promethazine, betahistine, and metoclopramide help treat dizziness, motion sickness, nausea, and vomiting. 

Another treatment option is vestibular rehabilitation — specific therapy to treat dizziness and balance dysfunction including diminishing response to visual motion, as well as balance training and exercises to stabilize eye movement. 

Is It Preventable?

In general, the best advice is to try and prevent migraine from occurring. Keeping track of and avoiding certain triggers may help prevent vestibular migraine. Depending on the individual, those triggers may include hunger, dehydration, certain foods and additives, lack of sleep, bright lights, or strong odors. 

What Causes It?

Similar to other types of migraine syndromes, vestibular migraine tends to be heritable. Women experience this condition more than men, and their symptoms may worsen around menstruation. 

Clinicians often see people display symptoms of dizziness and vertigo if they already get migraines, or have a family history of migraine or motion sickness. Certain migraine triggers might also be responsible, including changes in sleep patterns, certain foods like chocolate, aged cheese and red wine, or food additives like MSG.

Possibly involved in, or affected during, a vestibular migraine episode are:

  • Gravity receptors in the inner ear known as otolith organs. Research notes that their signals to the brain may become distorted in people with vestibular migraine.
  • The cerebellum, located at the back of the brain and involved in balance and coordination.
  • Insula, part of the cerebral cortex known to include vestibular information processing among its many functions.

What Are the Symptoms?

Vestibular migraine can typically exhibit common migraine symptoms such as severe, throbbing headache, usually on one side of the head; nausea and vomiting; and sensitivity to light, smell, and noise. 

But people with vestibular migraine will experience additional symptoms even more prominent and debilitating than head pain, including: 

  • Vertigo (dizziness), typically lasting minutes to hours, and occasionally days
  • Unsteadiness and loss of balance, as if they’d been “pushed”
  • Sensitivity to motion
  • A feeling of being displaced in space, known as Alice in Wonderland Syndrome

How Is It Diagnosed?

Most people with vestibular migraine do not have vestibular symptoms at the same time as head pain, so onset of dizziness alone can make vestibular migraine challenging to diagnose. A number of other conditions can behave like it — and may even co-exist with it — including benign paroxysmal positional vertigo (BPPV), Méniére’s disease, and transient ischemic attack (“mini-stroke”). 

A healthcare professional may order testing to rule out these other disorders. They will also consider the patient’s migraine history and the repetitiveness, severity, and length of their vertigo episodes, and will note if other migraine symptoms have been known to occur simultaneously with the vertigo.

How Is It Treated?

Use of standard migraine treatments, such as NSAIDs, triptans, and anti-CGRP medications, may decrease migraine activity in general, improving all symptoms including vestibular activity.  Some studies show that drugs typically used for vertigo may help to alleviate vestibular migraine. Drugs such as promethazine, betahistine, and metoclopramide help treat dizziness, motion sickness, nausea, and vomiting. 

Another treatment option is vestibular rehabilitation — specific therapy to treat dizziness and balance dysfunction including diminishing response to visual motion, as well as balance training and exercises to stabilize eye movement. 

Is It Preventable?

In general, the best advice is to try and prevent migraine from occurring. Keeping track of and avoiding certain triggers may help prevent vestibular migraine. Depending on the individual, those triggers may include hunger, dehydration, certain foods and additives, lack of sleep, bright lights, or strong odors. 

Sources

 

  1. Johns Hopkins Medicine. Vestibular MIgraine. https://www.hopkinsmedicine.org/health/conditions-and-diseases/vestibular-migraine
  2. Headache. Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine. https://pubmed.ncbi.nlm.nih.gov/18052952/
  3. Ann Indian Acad Neurol. The Treatment of Vestibular Migraine: A Narrative Review. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7887465/
  4. Youtube. Treatment of Vestibular Migraine: A talk with Dr. Michael Teixido from the 2022 Migraine World Summit. https://www.youtube.com/watch?v=xZbygczlRBQ
  5. NIH/National Library of Medicine. Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6276353/
  6. Journal of Neuroophthalmology. Vestibular Migraine: How to Sort it Out and What to Do About it. https://pubmed.ncbi.nlm.nih.gov/31094996/
  7. Current Rheumatology Reviews. Migraine and Central Sensitization: Clinical Features, Main Comorbidities and Therapeutic Perspectives. https://pubmed.ncbi.nlm.nih.gov/26717950/
  8. Frontiers in Neurology. New Insights into Pathophysiology of Vestibular Migraine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4319397/
  9. Frontiers in Neurology. Central Integration of Canal and Otolith Signals is Abnormal in Vestibular Migraine. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4226145/
  10. Behavioral Neurology. Recent Advances in the Understanding of Vestibular Migraine. https://pubmed.ncbi.nlm.nih.gov/27821976/

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