Vestibular Migraine - the most common cause of dizziness?


Have you ever heard of the term Vestibular Migraine? Most people have not. Yet, it's possibly the most common cause of dizziness. Migraine affects approximately 1 in 7 people worldwide (1) and is the second most common cause of disability among working-age adults (back pain being the first) (2). People who suffer from migraine will experience a myriad of symptoms including, but not limited to: pulsing or throbbing headache, sensitivity to light or sound, nausea and/or vomiting, brain fog, visual changes, irritability, and even dizziness. When there is a significant relationship between common migraine symptoms and dizziness, you may suffer from what is now known as vestibular migraine (previously migraine-associated vertigo or dizziness, migrainous vertigo, or migraine-related vestibulopathy).


How do I know if I have vestibular migraine?

Vestibular migraine in the most common neurological cause of dizziness with a 1-year prevalence between 1 and 2.7% of the population (3). Benign Positional Paroxysmal Vertigo (BPPV) is thought to be the most common cause of dizziness with a 1-year prevalence of 1.6%. So depending on what study you read, vestibular migraine may even be more common than BPPV. Vestibular migraine tends to affect women more than men (up to 4 times more) and typically occurs in the late 30s or early to mid 40s. More than half of people with vestibular migraine have a family history of migraine (3).


Diagnostic Criteria of Vestibular Migraine (4)

The diagnosis of vestibular migraine involves a thorough history of a person's symptoms and clinical examination of vestibular function to rule out any other sources of dizziness. Once all other possible causes of dizziness have been ruled out, there is specific diagnostic criteria based on the person's history.

  1. At least 5 episodes of moderate to severe vestibular symptoms lasting 5 minutes to 72 hours, or several days.

  2. Current or previous history of migraine with or without aura (symptoms that precede a migraine).

  3. One or more migraine features with at least 50% of the vestibular episodes. These features may be:

  4. Headache with at least two of the following qualities: one-sided, throbbing or pulsatile, moderate to severe intensity, triggered by routine physical activity

  5. Light or sound sensitivity

  6. Visual aura such as flashing of lights, blind spots, or visual distortions

  7. Not accounted for by another vestibular or headache diagnosis.

Based on this criteria, I want to point out that patients with vestibular migraine may not experience a headache at all. Looking at this diagnostic criteria, you only need one migraine feature with your vestibular episode, and that feature may not be a headache.


Symptoms other than dizziness (2)

Patients may experience a variety of symptoms other than dizziness, including:

Ear symptoms

Fullness, pressure, muffled hearing, ringing (tinnitus)

Visual symptoms

Blurred vision, double vision, impaired depth perception (misjudging distances), visual snow or static

Cognitive symptoms

​Brain fog, fatigue, difficulties with work finding

Mood changes

Irritability, anxiety, depression

​Sensory symptoms

​Numbness, tingling, burning, a heightened pain response to touch (known as allodynia)

​Autonomic symptoms

​Sweatiness, clamminess, nausea, vomiting, pallor

Common Triggers

While triggers do not cause vestibular migraine, they may aggravate the above symptoms. These include:

  • Head movement or positional changes

  • Visually busy environments like grocery stores, big crowds, or watching movies on big screens

  • Stress

  • Sleep deprivation

  • Bright lights or loud sounds

  • Weather/pressure changes

  • Hormonal fluctuations such as menses, pregnancy, or menopause

  • Food triggers

"Victory over Vestibular Migraine"

There is no one treatment for vestibular migraine. It is a multi-factorial approach focusing on migraine management, trigger avoidance, living "brain healthy", vestibular rehabilitation, and understanding your diagnosis.


Migraine Management

Before beginning vestibular rehabilitation, it is important to have a successful migraine management plan with your primary healthcare provider. You will be more successful with vestibular rehabilitation if your migraines are under control. For some of my patients, this takes the form of preventative or abortive migraine medications such as triptans (i.e. Imetrex), anti-convulsants (i.e. Topamax), or selective serotonin re-uptake inhibitors (i.e. Effexor XR). Other patients work with their naturopath and use supplements such as magnesium glutamate, riboflavin, or co-enzyme Q-10. There has also been research to support the use of non-invasive vagus or trigeminal nerve stimulators such as gammaCore.


Trigger Avoidance

While there are common symptom triggers as listed above, what provokes your vestibular migraine is unique to you. Therefore, identifying your specific triggers is an important preliminary step to treating your symptoms. I recommend patients keep a journal of what they do, what they eat or drink, how they sleep, and their daily stress level, so they can start to make connections between specific triggers and their symptoms. Then, it's a process of coming up with a plan on how to live your life while avoiding triggers. This can take the form of home modifications such as putting dimmers on light; workplace modifications such as requesting a workspace with minimal noise, bright lights, or visual stimulation; and oftentimes, avoiding dietary triggers. I love this website The Dizzy Cook. This is a treasure trove of migraine-friendly recipes that are easy and delicious. Alicia Wolf, the creator, also suffers from vestibular migraine and offers the unique perspective of someone struggling with this diagnosis and how diet and other strategies have helped her get her life back.


Living "Brain Health"

We've known migraine to be a vascular condition, but we are also learning that there is a neural component as well. This is why maintaining a healthy environment for those neurons is important, not just for vestibular migraine, but for overall health. Brain health is such an important, yet grossly under-examined topic. I once read a book that highlighted the irony of all the ways in which we are told to take care of our heart (aerobic exercise, avoid fatty foods, don't smoke), yet we are never told how to take care of our brains. Many people see a cardiologist regularly for preventative care, but only see a neurologist when things get serious. Why is that? Anyway, I digress. The basic needs of our brains are oxygen, nutrients, and stimulation. So basic brain health takes the form of a healthy diet and regular hydration for nutrients, cardiovascular exercise to get oxygen and nutrients to the brain, stress management and quality sleep to restore the brain, and regular stimulation through social activities and learning new skills.


Vestibular Rehabilitation

Many patients struggling with vestibular migraine are de-conditioned as they have avoided or stopped physical activities that may provoke their symptoms. They also tend to be visually dependent meaning they over-rely on vision for balance and spatial awareness. And finally, most, if not all of my patients, experience a feeling of unsteadiness with walking and daily activities. Therefore, a comprehensive vestibular rehabilitation program should address each of these areas. I work with my patients in each of these realms, developing a program targeted to address their specific impairments that carefully progresses them towards more exercise, more activity, and increased balance challenges. It is important that you seek care from a specialized vestibular therapist, as pushing too much too fast can make your condition worse. Dr. Joseph Furman, a neurologist and prominent researcher in the area of vestibular migraine, has said:

"Vestibular migraine is the only vestibular diagnosis in which PT can make the patient worse if not treated by a specialist."


As of the writing of this, there are no randomized control trials to date on the efficacy of vestibular rehabilitation in the treatment of vestibular migraine. However, preliminary studies show significant reduction of symptoms and improvements in dynamic balance in patients who participate in vestibular rehab, especially when combined with a migraine management plan from their primary healthcare provider (5).


Knowledge is power

For patients diagnosed with vestibular migraine, I always recommend they read Dr. Shih Beh's book Victory Over Vestibular Migraine. This book is the first of its kind to comprehensively synthesize the research about this diagnosis in a way that patients understand. After reading this, patients come to me saying things like " this is exactly what I'm dealing with" and "finally, someone gets it!" Just understanding what is going on with your body can play a huge part in starting to feel better!



References

  1. American Migraine Foundation. The facts about migraine. March 28, 2019. Accessed August 27, 2022.

  2. Beh, Shih C. Victory over Vestibular Migraine. 2nd edition. 2021.

  3. Beh SC, Masrour S, Smith SV, Friedman DI. The Spectrum of Vestibular Migraine: Clinical Features, Triggers, and Examination Findings. Headache J Head Face Pain. 2019.

  4. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: Diagnostic criteria. Journal of Vestibular Research. 2012;22(4):167-172.

  5. Alghadir AH, Anwer S. Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review. Front Neurol. 2018.