Vestibular migraine is one of the subtypes of migraine that progresses with dizziness (vertigo) and balance disorder. The majority of patients apply to different branches for many years saying “Everything is normal but I have dizziness,” “My examinations came out clean but my complaint doesn’t go away”; they often receive wrong diagnoses and are exposed to unnecessary treatments. This delay seriously reduces quality of life.

Headache is not always present in vestibular migraine. In fact, in some people, the headache period ended years ago but dizziness attacks appear with hormonal periods such as menopause. Therefore, vestibular migraine should definitely be considered in people with a history of migraine and experiencing unexplained dizziness.

During vestibular migraine attacks, spinning sensation, dizziness, imbalance in the form of swaying, nausea, ear pressure, and light-sound-smell sensitivity can be seen. While some attacks are accompanied by classic migraine headache, sometimes only dizziness can be the symptom. This situation is also an important factor that makes diagnosis difficult.

Scientific research shows that vestibular migraine is the second most common cause of vertigo. It is seen 2-3 times more in women compared to men and appears especially in the 30-50 age range. When it becomes chronic, it can significantly affect the person’s social life, work performance, and mental health.

The good news is: Vestibular migraine is a treatable disease. With correct diagnosis and neurology follow-up, dizziness attacks can be completely controlled and quality of life can be regained.

In this guide, you will find causes, symptoms, diagnostic methods, and the most current treatment options for vestibular migraine with scientific accuracy, in a language everyone can understand.

What is Vestibular Migraine?

Vestibular migraine is a special form of migraine that appears with dizziness (vertigo) and balance disorder. Unlike classic migraine headache, dizziness is the main symptom of this disease and can develop even without headache. Therefore, many patients can receive different diagnoses for a long time and reach correct treatment late.

Vestibular migraine occurs as a result of disruption of sensitive connections between the brain’s migraine mechanisms and balance system (vestibular system). Excessive stimulation of the trigeminovestibular network, imbalance of neurochemical substances such as serotonin and CGRP trigger vertigo attacks.

Dizziness seen in this disease can be in different forms:
• Rotational vertigo
• Floating / sliding sensation in space
• Imbalance in walking
• Dizziness triggered by visual stimuli

Attacks can last from seconds to days and are generally triggered by light, sound, movement, stress, sleep deprivation, or hormonal changes. While some attacks are accompanied by migraine-type headache, sometimes only dizziness can be seen.

For vestibular migraine diagnosis, the patient generally needs to have migraine history and vestibular complaints need to be related to migraine attack characteristics. This diagnosis is made according to criteria determined by the International Classification of Headache Disorders (ICHD) and Bárány Society. Additionally, ear diseases and other causes of vertigo must be excluded.

Vestibular migraine, which is a treatable disease when correctly diagnosed, can greatly improve patients’ quality of life when followed by neurology specialists.

What Causes Vestibular Migraine?

Although the exact cause of vestibular migraine is not fully known, it is accepted that the disease occurs as a result of complex interaction between migraine mechanisms and the balance system. Genetic predisposition, hormonal fluctuations, changes in brain chemistry, and environmental triggers are the main factors of the disease.

Research shows that a large portion of vestibular migraine patients have family members with migraine history. This suggests that genetic predisposition has an important role in the disease.

Irregular functioning of neurochemical systems such as serotonin, dopamine, and CGRP in the brainstem can trigger both migraine pains and dizziness attacks. When these substances affect balance centers, vertigo, dizziness, and imbalance can appear.

The main reason vestibular migraine is seen more frequently in women is hormonal changes. Situations such as menstrual period, pregnancy, menopause, or birth control pills affect estrogen levels and can increase attack frequency.

In some patients, hypersensitivity of the network mechanism called trigemino-vascular system can lead to vertigo attacks by affecting balance centers in the brainstem.

Additionally, vestibular migraine can also be triggered by many environmental factors:
• Sleep deprivation, stress, anxiety
• Staying hungry, skipping meals
• Light, sound, smell sensitivity
• Long-term screen use
• Weather and pressure changes
• Sugary and processed foods, caffeine, alcohol

In some people, movement sensitivity, motion sickness since childhood, panic disorder, or presence of other pain syndromes can increase the risk of developing vestibular migraine.

In conclusion, vestibular migraine is not due to a single cause; it is a neurobiological disease that occurs with the interaction of many factors. Therefore, treatment approach should also be personalized.

International Classification of Headache Disorders (ICHD-3) and Bárány Society Diagnostic Criteria- A1.6.6 Vestibular Migraine

1. At least five attacks meeting criteria C and D
2. Current or past history of
   1.1 Migraine without aura or 1.2 Migraine with aura diagnosis in the patient
3. Vestibular symptoms of moderate or severe intensity³, lasting between 5 minutes and 72 hours⁴
4. At least one of the following three migrainous features accompanies at least half of the attacks:
5. Headache with at least two of the following features:
   • Unilateral location
   • Pulsating character
   • Moderate or severe intensity
   • Aggravation by routine physical activity
6. Photophobia and phonophobia
7. Visual aura
8. Not better accounted for by another ICHD-3 diagnosis or another vestibular disorder

Notes

1. Underlying migraine diagnosis should be coded separately.
2. Vestibular symptoms, according to Bárány Society Vestibular Symptom Classification and compatible with A1.6.6 Vestibular Migraine diagnosis, include:
   • Spontaneous vertigo:
     Internal vertigo (feeling of self-movement)
     • External vertigo (feeling that surroundings are spinning/flowing)
   • Positional vertigo: Occurs following head position change
   • Visually induced vertigo: Triggered by large or complex visual movement
   • Head movement-induced vertigo: Appears during head movement
   • Head movement-induced dizziness + nausea
     (Dizziness here is defined as spatial orientation disorder sensation; other dizziness types are not included in this classification.)
3. Vestibular symptom severity:
   • Moderate: Makes daily activities difficult but doesn’t completely prevent them
   • Severe: Daily activities cannot be maintained
4. Attack duration is quite variable:
   • Minutes in 30% of patients
   • Hours in 30% of patients
   • Can last several days in 30% of patients
   • In 10% of patients, short attacks lasting only seconds but repetitive with head movement or visual stimulus can be seen
     In these cases, attack duration is evaluated as the total period when repetitions are seen.
     Rarely, complete recovery can take 4 weeks but core attack generally doesn’t exceed 72 hours.
5. Single accompanying symptom is sufficient in a single attack; there can be different symptoms in different attacks.
   Accompanying symptoms can appear before, during, or after vestibular symptoms.
6. If clinical evaluation doesn’t indicate another vestibular disease; or if excluded by investigations; or even if there is another accompanying vestibular disease but attacks are clearly distinguishable, vestibular migraine diagnosis can be made.
   Additionally, since vestibular stimulus can trigger migraine attack, conditions where migraine is added to vestibular disorder should also be considered in differential diagnosis.

How is Vestibular Migraine Diagnosed?

Vestibular migraine diagnosis is a condition that can remain as “dizziness whose cause cannot be found” for years when not done correctly. The foundation of diagnosis consists of detailed disease history, neurological and vestibular examination, and international diagnostic criteria. Because there is no single blood test or imaging method showing vestibular migraine.

Clinical Evaluation: The Most Important Stage of Diagnosis

Your doctor queries in detail:

• In which situations dizziness started
• How long it lasted
• Its relationship with visual movement, light and sound sensitivity
• Nausea, headache, aura history
• Its relationship with hormonal periods and stress

This information is decisive in diagnosis.

Neurological and Vestibular Examination

The following evaluations are made in examination:

• Balance tests
• Symptom change depending on head position
• Presence of nystagmus (eye tremor)
• Coordination tests

Examination is generally normal outside attacks in vestibular migraine, which is one of the factors making diagnosis difficult.

Supportive Tests (Not Mandatory in Every Patient)

Auxiliary tests are requested in some cases:

• Audiometry (hearing test): Generally normal → Important in differential diagnosis from Meniere’s
• VNG, caloric test, VEMP: Provides information about vestibular function
• Brain MRI: To rule out another structural disease

Normal MRI does not mean there is no vestibular migraine — in this disease, MRI is often completely normal.

What Needs to Be Excluded in Differential Diagnosis

• Meniere’s disease (hearing loss accompanies)
• BPPV (position-dependent short vertigo)
• Vestibular neuritis (single long-duration attack)
• Cerebellar diseases
• Acoustic neuroma

Keeping a Diary Is Very Valuable in Diagnosis!

With a dizziness diary:

• Duration and frequency of attacks
• Headache and dizziness relationship
• Triggers
• Response to treatment

clearly emerge. This is very important for correct diagnosis and correct treatment.

Vestibular migraine is a disease requiring clinical diagnosis.
Consulting with a neurology specialist early prevents unnecessary tests and treatments.

Vestibular Migraine Treatment

Vestibular migraine treatment requires a multifaceted approach. The aim is not only to stop dizziness; but to reduce attacks, increase quality of life, and regain control in daily life. Treatment is planned for each patient and is built on three basic principles:

Lifestyle Adjustments (Foundation Stone of Treatment)

Identifying migraine triggers and staying away from them is of great importance. Most patients report that their attacks significantly decreased with lifestyle adjustments alone.

Recommendations:

• Regular sleep hours (going to bed and waking up at the same time every day)
• Healthy eating without skipping meals
• Adequate water consumption
• Stress management (meditation, breathing exercises)
• Daily light exercises
• Avoiding migraine trigger foods
  (Chocolate, cheese, fermented products, caffeine, alcohol, foods with additives)

Acute Attack Treatment (Intervention During Attack)

During attack, the target is to quickly control dizziness and nausea.

Medications used:

• Triptans: Sumatriptan, rizatriptan, zolmitriptan
  (can stop attack)
• Antiemetics: Metoclopramide, ondansetron
  (for nausea-vomiting)
• Vestibular suppressants: Meclizine, dimenhydrinate
  (short-term use!)

These medications should be used not continuously, but only during attack periods.

Preventive (Prophylactic) Treatment

In cases where vestibular migraine attacks are experienced frequently or seriously affect quality of life, preventive medication treatment is started. The aim is to prevent attacks from occurring, reduce the severity and duration of dizziness. The effect of these medications generally starts to be noticed within 4-8 weeks and treatment is often continued for at least 6-12 months.

The most frequently used drug groups in preventive treatment and their advantages are as follows:

Beta-blockers, especially propranolol and metoprolol, are among first-line drugs in vestibular migraine treatment. They are quite effective in reducing both dizziness and migraine pains. They also have blood pressure and heart rhythm regulating effects.

Calcium channel blockers, especially flunarizine and verapamil, are frequently preferred because they increase sleep quality. They can also show relaxing effects in patients with high anxiety levels.

Anticonvulsant drugs topiramate, lamotrigine, and valproate provide significant improvement in both headache and vestibular symptoms by suppressing the basic mechanisms of migraine. Especially topiramate in patients with weight problems, lamotrigine in patients with accompanying mood disorders can be preferred.

Antidepressants, especially amitriptyline and venlafaxine, are an important treatment option because they also improve accompanying insomnia, anxiety, and depression symptoms. They also provide benefit in patients with neck muscle tension.

Which of these medications will be appropriate is determined according to the patient’s age, accompanying diseases, medications used, and symptom severity. During treatment process, regular controls, evaluation of medication effectiveness, and treatment adjustment when necessary must definitely be done.

Vestibular Rehabilitation (Balance Therapy)

Very effective especially in patients experiencing movement sensitivity and imbalance.

• Gaze stabilization exercises
• Balance and walking exercises
• Virtual reality-based treatments

Success rate increases when applied with physiotherapist accompaniment.

Migraine-Specific Treatment Options

Standard treatments may be insufficient in some patients. In this case:

• If patient’s headache is at chronic migraine frequency, Botox (PREEMPT Protocol)
  → Effective in chronic migraine + vestibular symptoms
• CGRP monoclonal antibodies
  (Erenumab, Fremanezumab, Galcanezumab)
  → Can provide significant reduction in attack frequency

Very encouraging results are reported especially in vestibular migraine patients without even headache.

Conclusion: Control Is Possible with Correct Treatment

Vestibular migraine is a disease that can last for years but can be controlled with correct treatment.
70-80% of patients experience significant improvement with appropriate treatment.
Regular follow-up and lifestyle changes increase success.

Frequently Asked Questions About Vestibular Migraine

1. What is the Difference Between Vestibular Migraine and Normal Migraine?

Although vestibular migraine originates from the same mechanisms as classic migraine, the main complaint is not headache, but dizziness and balance disorder.
In migraine, headache is dominant and has pulsating character lasting 4-72 hours. In vestibular migraine, vertigo attacks can last between 5 minutes and 72 hours and there may not be headache. The non-simultaneous occurrence of headache and dizziness makes diagnosis difficult.

Vestibular migraine:

• Dizziness, vertigo, imbalance are prominent
• Light, sound sensitivity and nausea can accompany
• Headache can be mild or may not exist at all

Vestibular migraine is a special subtype of migraine affecting the vestibular system.

2. How Is Vestibular Migraine Diagnosed? Which Tests Are Done?

Diagnosis is largely made clinically.
There is no specific blood test. International Headache Society & Bárány Society diagnostic criteria are taken as basis.

Methods used in diagnosis:

• Detailed history and symptom analysis (at least 5 vertigo attacks, 5 min-72 hour duration)
• Presence of migraine history
• Migraine-specific symptoms accompanying (photophobia, phonophobia, aura, nausea)
• Hearing tests (audiometry) → generally normal
• Vestibular tests (VNG, caloric test) → generally normal or mildly impaired
• MRI → used only to exclude other diseases

Patient diaries are very valuable in vestibular migraine diagnosis.

I recommend recording your headache and dizziness attacks before going to a neurology doctor and showing them to your doctor during your examination. This diary will be very useful for your doctor to evaluate the frequency, severity, and relationship of your headache and dizziness attacks with each other.

3. How Is Vestibular Migraine Treated? Is Medication Use Mandatory?

Medication is not mandatory in every patient. Treatment consists of three basic steps:

Avoiding triggers + lifestyle adjustments
Attack treatment (triptans, antiemetics, vestibular suppressants)
Preventive treatment (if attacks are frequent or severe):

• Beta-blockers: Propranolol, Metoprolol
• Calcium channel blockers: Flunarizine, Verapamil
• Anticonvulsants: Topiramate, Lamotrigine
• Antidepressants: Amitriptyline, Venlafaxine

Additionally:
Vestibular rehabilitation, stress management, regular sleep and exercise are main parts of treatment.
70-80% of patients experience significant improvement with correct treatment.

4. Which Foods Trigger Vestibular Migraine? How Should I Eat?

Classic migraine triggers also apply to vestibular migraine. Most common triggers:

• Chocolate, aged cheeses (cheddar, roquefort)
• Processed meat products (salami, sausage, ham)
• Monosodium glutamate (MSG) and packaged foods
• Red wine and alcohol
• Excessive caffeine consumption or sudden cessation
• Aspartame and artificial sweeteners

Nutrition recommendations:

• Regular meals, avoid long hunger
• Plenty of water
• Unprocessed natural foods
• Keep a nutrition diary to identify personal triggers

5. Does Vestibular Migraine Pass? Does It Last for Life?

Vestibular migraine shows chronic tendency but is a controllable disease.
With appropriate treatment, most patients experience significant reduction in attack frequency and severity.

• Improvement over time in 60-70% of patients
• Attacks may decrease in post-menopausal women
• Cases where it completely disappears can also be seen

Normal life is possible with early diagnosis and treatment.

6. If MRI Is Normal, Can’t There Be Vestibular Migraine?

On the contrary, MRI is normal in a large portion of vestibular migraine cases.
Because vestibular migraine results not from structural damage to the brain but from disruption of its functional networks.

MRI is taken for the following purpose:

• To exclude other serious diseases (tumor, MS, stroke)
• To rule out inner ear pathologies

Normal MRI does not exclude vestibular migraine. Neurology specialist will make your diagnosis and plan the most appropriate treatment for you.

For a Turkish scientific resource about vestibular migraine, you can read my article titled “Diagnosis and Treatment in Vestibular Migraine” from the link below.

https://tjn.org.tr/abstract/231/tur