Vestibular Migraines · What Are They, Signs and Symptoms, Treatment, and More

Vestibular migraines are a type of migraine associated with disturbances in the sensory organ responsible for balance and spatial orientation, called the vestibular system. Dysfunction of the vestibular system can give rise to symptoms like dizziness or vertigo, which is a false sensation of self-movement or movement of the surroundings that happens when the body is at rest.  

Vestibular migraines are often diagnosed when vertigo occurs during, before, or shortly after a migraine attack. While many medications can help manage the headache associated with migraines, there are no specific treatments to treat vertigo symptoms. Therefore, current management is focused primarily on reducing the frequency of migraine attacks. 

The exact cause of vestibular migraines is not fully understood, however, the same events that give rise to migraine attacks are likely involved in the development of vestibular symptoms.  

Migraine attacks often begin with the activation of the trigeminal nerve, which is a cranial nerve involved in the sensation of the head and face. Trigeminal activation leads to the release of neurotransmitters like calcitonin gene-related peptide (CGRP), which is involved in transmitting pain signals along the trigeminal pathway. The release of these neurotransmitters causes the blood vessels around the brain to dilate, which contributes to the throbbing headache characteristic of migraines. These vascular changes also trigger a phenomenon known as cortical spreading depression, which is a wave of electrical activity that propagates across the brain, temporarily disrupting brain function. This wave of cortical depression is thought to play a role in the aura phase of migraines and the initiation of the headache. It may also affect the brain areas responsible for processing vestibular information.  

Like regular migraines, vestibular migraines are often associated with specific triggers, such as hormonal changes, stress, sleep deprivation, dehydration, certain foods like chocolate or cheese, and drinking wine, among others.  

Signs and symptoms of vestibular migraines can begin several years after the first migraine attack. While some people experience classic migraine headaches along with vestibular symptoms, others may have predominantly vestibular symptoms without the headaches.  

The most commonly reported vestibular symptom is vertigo. A person with vertigo might feel as if they or the objects around them are spinning or moving when they are not, making it difficult to walk or even maintain balance while standing upright. Other symptoms of vestibular migraine include dizziness induced by head movements, motion sickness, and, less commonly, hearing loss. These symptoms can last anywhere from a few minutes to days, and they can occur during, before, or shortly after a migraine attack. 

Most individuals with vestibular migraines also experience migraine headaches. The migraine itself usually feels like a pounding or pulsating pain, typically localized to one side of the head. It can be accompanied by nausea, vomiting, and sensitivity to lights, sounds, or smells—called photophobia, phonophobia, and osmophobia, respectively. Often, migraine headaches are preceded by an aura, where people experience strange smells, lights, visual disturbances, or even hallucinations before the onset of the migraine. Other symptoms include fatigue, difficulty with coordination, and difficulty concentrating. 

Diagnosis of vestibular migraines is based on a set of clinical criteria established by the International Headache Society (IHS). The diagnosis requires a current or past history of migraine along with vestibular symptoms lasting from 5 minutes to 72 hours, with at least half of vestibular episodes associated with migrainous features.  

A thorough history and physical examination can help distinguish between vestibular migraines and other causes of vertigo, like benign paroxysmal positional vertigo (BPPV) or Ménière disease. Although vestibular migraines are one of the most common causes of vertigo, they are particularly challenging to diagnose because the relationship between vestibular symptoms and migraine attacks may not be evident in some cases.  

Treatment of vestibular migraines is very similar to that of regular migraine headaches. Acute treatment involves non-steroidal anti-inflammatory agents (NSAIDs), like ibuprofen or naproxen, and, in severe cases, triptans like sumatriptan, zolmitriptan, or rizatriptan. These medications act on the initiating mechanisms of migraine, so they work best if used at the first sign of a migraine attack. Vestibular suppressants, like benzodiazepines (e.g., diazepam) or antihistamines (e.g., dimenhydrinate), may also be prescribed to relieve vertigo symptoms, particularly during acute episodes. 

People who have multiple episodes of migraines can benefit from preventive treatment. Treatment options include beta-blockers, like propranolol, timolol, or metoprolol; calcium-channel blockers, like verapamil or flunarizine; tricyclic antidepressants, like amitriptyline; and some anti-epileptic medications, like topiramate.   

Another treatment is onabotulinum toxin A, more commonly known as Botox, which is injected into the head and neck muscles every few months. Finally, there is a new class of medications called anti-CGRP antibodies (e.g., erenumab, fremanezumab, and galcanezumab), which target the calcitonin gene-related peptide, or its receptor, reducing pain transmission through the trigeminal pathway.  

In addition to pharmacological treatment, people with vestibular migraines may benefit from vestibular rehabilitation, a form of physical therapy aimed at improving balance, reducing dizzy spells, and developing compensatory mechanisms in the vestibular system. Newer therapies, like vagal nerve stimulation, are currently being researched to treat migraine-associated vertigo. While it is still an experimental treatment, it is thought that stimulation of the vagus nerve could influence the release of neurotransmitters in the nervous system, thereby regulating pain perception.