Vestibular migraine

Vestibular migraine presents with recurrent attacks of spontaneous or positional vertigo, often accompanied by nausea, photophobia, phonophobia, or visual aura. The episodes typically last between 5 minutes and 72 hours, and the diagnosis requires a current or past history of migraine according to ICHD-3 criteria.¹ The vertigo may occur independently of headache, and many patients experience motion sensitivity between attacks.

Diagnosis is clinical, as no biomarker or imaging finding is specific. The ICHD-3 defines vestibular migraine as at least five episodes of vestibular symptoms of moderate or severe intensity, with at least half of the episodes accompanied by migraine features. Exclusion of other causes, such as Menière's disease or transient ischemic attacks, is essential.

The underlying mechanisms of vestibular migraine are not fully understood, but evidence points to a complex interplay between the trigeminal and vestibular systems. Functional imaging studies have shown activation in the vestibulo-thalamo-cortical pathways during attacks, and altered processing of vestibular signals in the brainstem and cortex is thought to contribute.²

Genetic factors play a role, as vestibular migraine often runs in families, and some studies have linked it to mutations in the CACNA1A gene, which is also associated with familial hemiplegic migraine and episodic ataxia type 2.³ Neurotransmitter imbalances, particularly involving serotonin and calcitonin gene-related peptide (CGRP), are also implicated, and these pathways are targets for preventive therapies.

Treatment of vestibular migraine follows the general principles of migraine management, combining acute abortive therapy with preventive measures. For acute attacks, triptans such as sumatriptan and zolmitriptan have shown efficacy in controlled trials, and antiemetics may be used for symptom relief.

Preventive treatment is recommended for patients with frequent or disabling attacks. Commonly used agents include beta-blockers (propranolol), calcium channel blockers (verapamil), and antiepileptic drugs (topiramate). Lifestyle modifications, including regular sleep, hydration, and avoidance of triggers such as stress, caffeine, and certain foods, are also important.⁴ Vestibular rehabilitation therapy may help reduce motion sensitivity and improve balance between attacks.

Vestibular migraine is often underdiagnosed, partly because many patients do not report headache during vertigo attacks. A 2019 study found that up to 30% of patients diagnosed with Menière's disease may actually have vestibular migraine, leading to misdirected treatments.

Another overlooked aspect is the overlap with motion sickness: children with vestibular migraine often present with recurrent motion sickness rather than vertigo, and the condition may be mislabeled as "benign paroxysmal vertigo of childhood." Additionally, vestibular migraine can coexist with other vestibular disorders, such as benign paroxysmal positional vertigo (BPPV), complicating diagnosis. Recent research has also explored the role of CGRP antagonists (gepants) as a novel preventive option, with preliminary results showing promise.

Vertigo

A sensation of spinning or movement when no movement is occurring.

ICHD-3

The third edition of the International Classification of Headache Disorders, which provides diagnostic criteria for headache and related conditions.

CGRP

Calcitonin gene-related peptide, a protein involved in migraine pathophysiology.

Menière's disease

A disorder of the inner ear causing vertigo, tinnitus, and hearing loss.