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Vestibular migraine

When most people hear the term ‘migraine’, they think of severe head pain. However, in vestibular migraine, head pain isn’t the main feature.

Despite becoming more recognised, vestibular migraine is still underdiagnosed and misunderstood. 

In this article, we’ll delve into the various aspects of vestibular migraine, including its symptoms, diagnosis and treatment options. 

We will also talk about our approach and how at we provide successful physio treatment of this type of migraine.

What is vestibular migraine?

A vestibular migraine is a type of migraine that involves epsiodes that can be a combination of vertigo, dizziness and/or balance issues.

It can also be called migrainous vertigo, migraine-related dizziness or migraine with prominent vertigo. Less commonly used terms are ‘migraine-anxiety-associated dizziness’ and ‘migraine-related vestibulopathy’.

As a condition that has been described in the last 10 years, there is a lot of misunderstanding surrounding it, and under-diagnosis.

Patients frequently describe:

  • sensitivity to head motion
  • sensitivity to their visual surroundings, including movement
  • sudden feelings of imbalance or tilt

These symptoms can last for minutes, hours or days. This can significantly get in the way of sufferers doing their normal daily activities.

What is the difference between migraine aura and vestibular migraine? 

Migraine aura typically last for 5 minutes up to an hour, whereas the vestibular symptoms in vestibular migraine can last for hours to days.

How common is it?

Vestibular migraine is surprisingly common. In fact, it is thought to be the most common cause of spontaneous, non-positional, epsisodic vertigo.

The estimate is that it affects between 1% and 3% of the general population, and reported in up to 30% of people who attend specialist dizziness and headache clinics.

It is underdiagnosed, with one study showing that only 10% of people who met the diagnostic criteria were told that migraine was the cause of their vestibular symptoms.

It is more common in females than males, most typically starting in adulthood but can begin at any age.

How to diagnose vestibular migraines

The diagnosis of a vestibular migraine relies solely on clinical symptoms.

There are no gold standard laboratory tests, investigations or even clinical findings that confirm the diagnosis. 

Testing of vestibular function produces variable results and can’t be used to diagnose vestibular migraine, but can be used to rule out other possible reasons for vertigo.

The diagnosis is usually made by an ear, nose and throat (ENT) specialist or a neurologist, and needs to satisfy the criteria of the International Classification of Headache Disorders (ICHD-3).

The ICHD-3 is a classification document that is intended to differentiate headache and migraine types. 

To diagnose a vestibular migraine the ICHD-3 criteria are:

  • At least 5 episodes
  • A past or present history of migraines
  • Vestibular symptoms (vertigo or dizziness) lasting between 5 minutes and 72 hours
  • Migraine headache or other migraine associated symptoms in at least half of the episodes

What are the symptoms of vestibular migraine?

Vestibular migraine (VM) behaviour is quite variable. There are the vestibular aspects ie the dizziness, vertigo or balance disturbance, and the migraine aspects.

The vestibular symptoms can last from 5 minutes to 3 days, although shorter and longer periods are reported to happen (although this is at odds with the diagnostic criteria of ICHD-3)

These symptoms can mimic features of both benign positional paroxysmal vertigo (BPPV) and the auditory symptoms of Ménière’s Disease.

Some of the common migraine symptoms that can occur with vestibular migraine are:

  • Nausea/Vomiting
  • Photophobia – sensitivity to light
  • Phonophobia – sensitivity to sound
  • Visual aura – including loss of visual field, or patterns in the visual field

During acute attacks, most patients show involuntary eye movements called nystagmus.

The migraine symptoms and vestibular symptoms are usually quite different in nature and length, and often don’t happen at the same time.

Typically, the vestibular symptoms occur after the migraine head pain subsides. In some people the headache and vestibular symptoms never happen at the same time.

Can you get a vestibular migraine without a headache?

Head pain doesn’t need to be present for an episode to be a vestibular migraine.

This makes the diagnosis of vestibular migraine more challenging because of the overlap with other causes of dizziness or vertigo.

However, according to the diagnostic criteria, there do need to be episodes that have migraine or migraine-associated symptoms

These symptoms include head pain, but also the other neurological symptoms that can occur with migraine.

What is vertigo? 

Vertigo is the sensation that you are moving when you are not really moving, or a sensation of movement that is different or distorted compared to a normal head movement.

What causes vestibular migraine?

There is no confirmed cause for vestibular migraine, though there are many theories that have been proposed. 

There are many neural connections between the regions of the brain involved in migraine and headache generally, and the vestibular nuclei in the brainstem. 

The vestibular system ‘hyperexcitability’ that has been found in vestibular migraine may be related to the influences of any of these connections, or the vestibular organs themselves.

Findings that suggest that the processing of visual and spatial information is altered in vestibular migraine patients. It also suggests altered integration of all of this information that creates our perception of orientation in space.

What is the difference between benign paroxysmal positional vertigo and vestibular migraine?

Benign Paroxysmal Positional Vertigo (BPPV) is a vertigo condition where there is a false sense of motion after changing head position.

BPPV creates a sensation of vertigo, which can feel like either you or the room spinning, or that you are falling. The direction of spinning or falling will depend on the affected canal in your vestibular apparatus.

The usual pattern with BPPV is that this spinning or falling sensation eases within a minute.

The intensity of the vertigo can range from mild to severe.

There is often no sensation of vertigo or dizziness apart from after doing the triggering movement, but instead there can be a sense of lingering unsteadiness.

The difference is that vestibular migraine doesn’t have to be related to movement of the head or a change in position, though it often is.

Sensations of spinning, whirling or movement can be triggered by movement or visual stimuli eg movement of something in the visual field.

Whereas in BBPV the worse of the dizziness eases within a minute, in vestibular migraine it can last from a few minutes to several hours.

What is the difference between vestibular migraine and PPPD?

Persistent postural-perceptual dizziness (PPPD) is a relatively recent definition for a condition where people have ongoing dizziness or unsteadiness that is provoked by postural changes or visual motion.

There are many similarities in this presentation of dizziness to vestibular migraine. Migraine happens to be a common problem associated with PPPD.

Similar to vestibular migraine, PPPD is only defined by clinical symptoms without diagnostic investigation findings.

It is unknown if there is a pathological link between these two conditions.

What is the standard treatment for vestibular migraine?

It needs to be said that the evidence base for the medical treatment of vestibular migraine is of low quality (Smyth et al 2022). The pharmacological approach is an extrapoloation of what is used for other forms of migraine.

Medications for vestibular migraine are aimed at prevention, but there is insufficient evidence from randomised controlled trials to verify that any of the medications are effective for prophylaxis.

There are only a few randomised controlled trials on acute treatment for vestibular migraine attacks.

The common advice in the literature that vestibular migraine sufferers can be managed with lifestyle modifications, dietary changes, medication and vestibular physiotherapy. 

Dietary adjustments include the advice to eliminate triggers like red wine, aged cheeses, artificial sweeteners, MSG, caffeine, chocolate, processed meats and alcohol. This seems like a dramatic change unless these have been established as triggers in the individual patient.

Vestibular rehabilitation has been used to help symptoms in vestibular migraine as in other vestibular disorders.  Despite there being no randomised controlled trials looking at the effectiveness of vestibular physiotherapy in vestibular migraine, other studies do suggest its usefulness as a non-pharmacological approach.

What do we do to help vestibular migraine?

Similar to what we know about all headache and migraine types, altered information from the upper neck can contribute to hyperexcitiability of regions of the brainstem like the trigeminocervical nucleus. 

We know that anatomically, there are rich connections between this region and others, like the vestibular nuclei.

The treatment approach which has proven to be the most effective with out patients is identifying if there is a relevant upper neck contribution, and treating that using the Watson Headache Approach.

Through out training in the Watson Headache Approach and results with patients, we recognise that there is often an important contribution from the upper neck which is overlooked with other treatment approaches.

This can be identified through skilled assessment of the upper cervical spine on the first consultation by looking for key typical findings.

If a cervical component is involved, treatment can be begun immediately and we expect to see a change in symptom behaviour rapidly, that is within the first few sessions.

At the same time, we address any other factors contributing to the ongoing problem, and address factors that may help improve the situation, for example sleep, exercise and stress.

Summary

  • Vestibular migraine is one of the most common causes of dizziness.
  • It is still misunderstood and underdiagnosed.
  • Diagnosis is based purely on subjective questioning and the criteria of the ICHD-3.
  • Solid evidence to support medication treatment is lacking.
  • There is evidence for physiotherapy vestibular rehabilitaiton.
  • The Watson Headache Approach provides an effective method of identifying if a contribution exists from the upper cervical spine, and a rapid change if it does.

Your next steps

Our experience using the Watson Headache Approach allows us to quickly and accurately assess the upper cervical spine for the typical findings that would indicate its involvement.

Results of treatment using this approach are relatively fast – we usually know if we are having an effect within days, sometimes after the first treatment.

If you have vertigo or dizziness and you are struggling to get a diagnosis or effective treatment, it is worth having a chat with one of our Watson Headache Practitioners to see if we are able to help you.

Call (08) 7282 0871 or book online to organise a free chat with one of our Watson Headache Practitioners – Russell Mackenzie, Rob Benger, Lachlan Sutherland or Lisa Vernon.

 

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About the author

Picture of Russell Mackenzie
Russell Mackenzie
Russell is a physiotherapist and clinic owner in Adelaide, South Australia. He received his physiotherapy degree from UniSA in 1994, and has since also become a Credentialed McKenzie Therapist. Russell is the co-owner of Adelaide West Physio + Pilates and more recently, Adelaide West Headache Clinic, which was formed after becoming a Watson Headache Certified Practitioner to show his dedication and passion for headache and migraine treatment. Russell also aims to spread the word about the role of physiotherapy and non-surgical methods of helping persistent pain, low back pain and other conditions. Learn more about Russell on our About Us page.
Picture of Russell Mackenzie

Russell Mackenzie

Russell is a physiotherapist and clinic owner in Adelaide, South Australia. He received his physiotherapy degree from UniSA in 1994, and has since also become a Credentialed McKenzie Therapist. Russell is the co-owner of Adelaide West Physio + Pilates and more recently, Adelaide West Headache Clinic, which was formed after becoming a Watson Headache Certified Practitioner to show his dedication and passion for headache and migraine treatment. Russell also aims to spread the word about the role of physiotherapy and non-surgical methods of helping persistent pain, low back pain and other conditions. Learn more about Russell on our About Us page.
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