Vestibular migraine
Vestibular migraine is a common cause of recurrent episodic vertigo in patients with a personal history of migraine, diagnosed clinically by ICHD-3 criteria after excluding Meniere disease and central causes; acute attacks are treated like migraine with NSAIDs, antiemetics, and triptans, with prophylaxis mirroring standard migraine prevention.
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What this article covers
- Overview
Definition: vestibular migraine is a recurrent episodic vestibular disorder that occurs in patients with a personal history of migraine, in which vertigo or other vestibular symptoms are the dominant…
- Epidemiology
Frequency in vertigo populations: vestibular migraine is a common cause of episodic vestibular symptoms encountered in general medicine and otolaryngology practice.
- Risk factors
Personal history of migraine: the single most important risk factor; recurrent vestibular episodes in a patient without any migraine history should prompt reconsideration of the diagnosis.
- Pathophysiology
Shared mechanism with migraine: vestibular migraine is presumed to share the underlying neurobiology of migraine, including cortical and brainstem hyperexcitability and trigeminovascular activation…
- Clinical features
International Classification of Headache Disorders, 3rd edition (ICHD-3) diagnostic criteria (the clinical definition): at least 5 episodes of moderate to severe vestibular symptoms, each lasting…
- Differential diagnosis
Meniere disease: requires two or more episodes of vertigo lasting 20 minutes to 12 hours plus documented fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or aural fullness on…
- Diagnosis
Diagnosis is clinical, established by the ICHD-3 criteria above, after exclusion of other structural, otologic, and vascular causes of episodic vertigo; there is no confirmatory laboratory or imaging test.
- Management
First, treat the acute episode symptomatically the same way an acute migraine attack is treated: an NSAID such as ibuprofen 400-800 mg PO as a single dose for a mild-to-moderate episode, or a triptan for a moderate-to-severe episode.
- Complications
Falls and injury during vertiginous episodes, particularly in older patients or in occupational fall-risk settings.
- Prognosis
Generally favorable with treatment: most patients achieve meaningful reduction in attack frequency and severity with trigger management plus an appropriate prophylactic agent, mirroring outcomes in typical migraine prevention.
- Prevention
Initiate pharmacologic prophylaxis when episode frequency reaches 4 or more days per month, and almost always once frequency exceeds 10 days per month, mirroring the migraine-prevention threshold.
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Related articles
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Migraine is a primary episodic headache disorder diagnosed by ICHD-3 clinical criteria (recurrent attacks, 4-72 hours, pulsatile/unilateral pain with nausea or photophobia/phonophobia). First-line acute treatment is an NSAID or oral triptan started early in the attack; prevention with a beta-blocker, topiramate, or CGRP-targeted therapy is added once attacks are frequent or disabling.
- Meniere disease
Meniere disease is a chronic inner-ear disorder linked to endolymphatic hydrops, causing recurrent episodic vertigo with fluctuating sensorineural hearing loss, tinnitus, and aural fullness. Diagnosis is clinical, confirmed by audiometry; acute attacks are treated with antiemetics, and prevention relies on a low-salt diet (<2 g sodium/day) and diuretics.
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- Cerebellar stroke
Cerebellar stroke, ischemic or hemorrhagic infarction of the cerebellum, presents with vertigo, truncal ataxia, dysarthria, and limb incoordination and is diagnosed with brain MRI when CT is falsely reassuring. Its defining danger is delayed swelling that compresses the brainstem and fourth ventricle, which is treated with emergent decompressive suboccipital craniectomy.
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Medication overuse headache is a secondary headache disorder in which frequent use of acute headache medications transforms an underlying migraine or tension-type headache into near-daily pain. Management is discontinuing the overused agent and starting migraine-preventive therapy, with acute medication limited to 10 or fewer days per month.