Vestibular migraine

Vestibular migraine has been also called migraine-associated vertigo or dizziness and migrainous vertigo. Diagnostic criteria, according to the international headache classification, include a current or past history of migraine with or without aura, attacks lasting between 5 minutes and 72 hours, vestibular symptoms of moderate or severe intensity. These vestibular symptoms include spontaneous vertigo, positional vertigo occurring after a change of head position; vertigo triggered by a complex or large moving visual stimulus, head motion-induced vertigo occurring during head motion, head motion-induced dizziness with nausea. There is also a requirement for at least half of episodes to be associated with a typical migraine headache or visual aura.

These criteria are the result of a consensus arrived at by headache specialists, which makes them based on cases seen by these specialists, rather than large scientific studies. I’ve encountered some patients who do not have migraine headaches or visual auras, but probably still suffer from migraine-related dizziness or vertigo.

We also lack any studies of treatment for patients with vestibular migraine. My own observation is that vestibular symptoms improve with the treatment of migraine headaches. In patients who suffer from vestibular symptoms with few or no headaches we try similar treatments first – magnesium, CoQ10 and other supplements (we often check blood levels of RBC magnesium and CoQ10), regular aerobic exercise, and medications, such as gabapentin and nortiptyline. When headaches are very frequent we give Botox injections, which are not appropriate if headaches are infrequent.

The classification of headaches also lists benign paroxysmal vertigo as a condition which occurs in children and which may be associated with migraines. (This is different from benign positional vertigo which is triggered by a loose crystal in the inner ear and which can be cured with the Epley maneuver). This migraine-related vertigo usually occurs without a warning and resolves spontaneously after minutes to hours without loss of consciousness. Patients usually have one of the following features: nystagmus (beating movement of the eyes to one side), unsteadiness, vomiting, paleness, or fearfulness. The neurological examination, audiometry (hearing test) and vestibular functions (test also done by an ENT specialist) are normal between attacks.