Vestibular Migraine

by Joon Nah  BScPT  
Certified Vestibular Physiotherapist
updated Dec 13, 2021

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What are Vestibular Migraines?

Vestibular migraine is a chronic neurological disorder that causes episodes of migraine headaches combined with vestibular symptoms (dizziness, motion-related impairments). It is one of the most common conditions that causes people to experience vertigo and dizziness (up to 30% of the patients seen in dizziness clinics).

Vestibular migraine was previously known as Migraine Associated Vertigo (MAV), Migraine-Related Vertigo and Migrainous Vertigo. It can cause a significant disruption to your daily life, including difficulties working at your job, participating in physical activities, and functioning in your role as a partner or caregiver.

 

Vestibular Migraine Symptoms

What does a vestibular migraine feel like? Here are the most common symptoms that are reported by patients:

• Vertigo attacks (a sensation of irregular motion or spinning) that last for anywhere from seconds to days.
• Headaches that are throbbing and usually on one side of your head
• Other vestibular symptoms like generalized dizziness, motion sickness, light-headedness and imbalance
• Light and sound sensitivity
• Visual auras that include seeing patterns of lights or flashes and spots and in some cases, a temporary loss of vision
• Nausea and vomiting
• Head pressure or a heavy head sensation
• Sensitivity to motion or quick position changes
• Possibly ear fullness, ringing or temporary loss in hearing

NOTES:
1) Dizziness and migraine headaches often do not occur at the same time. In fact, in many cases the migraine symptoms occur for years before the dizziness or episodic vertigo symptoms begin.
2) Those with a longer history of vestibular migraines can start noticing symptoms in-between their attacks as well as during.

 

Risk factors for Vestibular Migraine

Vestibular migraine is a common condition and affects up to 3 % of our population. In many cases, we can’t predict who is more likely to experience vestibular migraines, however the following factors have been recognized:

• It is more common in females than males with some studies showing females are 5x more likely
• Though it can occur at any age, the average onset is at 38 – 50 years old
• There are some genetic links with most vestibular migraine sufferers reporting a family history of this condition.
• 78% have experienced a history of car sickness.
• Vestibular migraine patients often report a history of anxiety, depression and sleeping issues
• Benign Paroxysmal Positional Vertigo (BPPV) in children is seen be an early stage of vestibular migraine.

NOTE: Vestibular migraine is one of the most common causes of PPPD, which is a newer dizziness diagnosis and one is of the most top reasons patients experience chronic dizziness. Click here to learn more about Persistent Postural Perceptual Dizziness (PPPD).

 

What are triggers for Vestibular Migraine?

Vestibular migraine triggers vary depending on each individual. What may kickstart an episode for one person may have no effect on another. However, here is a list of the more common triggers reported by our patients:

• Stress (or more specifically, poor stress coping strategies to a stressful event)
• Weather changes (fluctuations in barometric pressure)
• Poor sleeping patterns or not enough sleep
• Bright lights
• Missed meals
• Onset of menstrual cycle in women
• Excessive movement stimulation (such as with amusement park rides)
• Disorienting visual stimulation (such as with a 3D movie)
• Dehydration
• Specific food choices (coffee, tea, aged cheese, red wine, monosodium glutamate, artificial sweeteners, chocolate, alcohol, processed meats)

 

What are the causes of Vestibular Migraine?

There are a few different theories as to why vestibular migraine occurs, however at this time it is largely unknown with more research needed. Some of the more likely theories include:

1) A lowered threshold to stimulation of your vestibular system, such as a poor tolerance to excessive head motion or visual motion.

2) Excessive stimulation of your peripheral vestibular system. That is, over-stimulation of your inner ear organ through movement, temperature change, pressure changes etc.

3) The thought that the dizziness is an aura type of migraine symptom, in the same way that migraine sufferers get visual auras with their attacks.

The affected areas are aggravated due to factors such as inflammation, neuro-chemical disturbances or blood flow changes. These changes to the neurology of your head can affect both your inner ear organ and vestibular nerves, and also the areas of your brain that process movement information. This means that migraine symptoms are different between patients and therefore can result in different choices for treatment.

 

How is Vestibular Migraine diagnosed?

Vestibular migraine is a highly under-diagnosed condition with most medical professionals unfamiliar with this term. In some reports, as little as only 10% of vestibular migraine sufferers are actually properly diagnosed with this disorder.

One reason is that the headaches associated with migraine associated vertigo don’t always accompany the dizziness. In fact, the headache portion of migraines usually occur first, sometimes even years before the vertigo symptoms begin. On average this difference is somewhere between 8-14 years.

Diagnosis of vestibular migraine is achieved through a careful review of a patient’s history, of their current symptoms and patterns and of ruling out of other causes for their episodes. Though a head scan such as an MRI or CT scan has a partial ability to show the lesions associated with general migraines, at this point these types of scans are not useful for diagnosing vestibular migraines.

Specific vestibular testing such as caloric tests and VEMPs can highlight problems with vestibular function, but generally cannot be used to specifically identify a vestibular migraine.

A diagnosis of vestibular migraine must involve the ALL of following:

1)  A migraine history with or without migraine aura.

2)  A minimum of 5 significant dizziness attacks that last for 5 min – 72 hours.

3)  At least half of the dizziness episodes must include one of the following:

• Migraine headaches that have a minimum of two of the following:

– single-sided headache
– pulsing in nature
– pain that is moderate or severe

• phonophobia or photophobia (sensitivity to sound or light)
• Visual aura

4)  No other vestibular condition that better accounts for these symptoms

 

Vestibular Migraine vs Meniere’s vs BPPV

There is a connection between Vestibular Migraines and other vestibular disorders including BPPV and Meniere’s Disease. One medical study noted that nearly 30% of those with Meniere’s disease also meet the criteria for Vestibular Migraine. And similarly, up to 18% of those with vestibular migraines ended up with the low frequency hearing loss commonly associated with Meniere’s disease. Studies also show that BPPV is the most common vestibular condition and is also more likely to exist in patient who suffer from vestibular migraine.

Both BPPV and Meniere’s Disease commonly involve attacks or episodes of vertigo and nystagmus (irregular eye reflex motions), similar to the vestibular symptoms that occur with vestibular migraines. Therefore, these conditions are often confused for one another, and can be difficult for medical professionals to differentiate.

Learn more about Meniere’s disease here and about BPPV here.

 

Vestibular Migraine Treatment

Treatment for vestibular migraine involves a combination of the conventional treatment for general migraine as well as vestibular rehabilitation to address the dizziness symptoms.

1)  Medications

• Anti-nausea, benzodiazepenes, vestibular suppressants, antihistamines, tricyclic antidepressants

2)  Lifestyle changes

• Sleep hygiene
• Stress management
• Anxiety/depression management
• Regular meals
• Routine physical activity and exercise – start with low impact physical activity, then try to engage in activities that involve coordination, balance, weight-shifting. (ping-pong, tennis, dancing)

3)  Avoiding vestibular migraine triggers

• Vestibular Migraine Diet – Avoiding coffee, tea, aged cheese, red wine, monosodium glutamate, artificial sweeteners, chocolate, alcohol, processed meats
• Staying hydrated
• Limiting activities that over-stimulate your vestibular sensors – (e.g. repeated spinning or movements that oscillate you back and forth)
• Limiting your exposure to confusing visual imagery – (3D movies, screen based theme park rides)

NOTE: if you are commonly affected by excessive exposure to sound and light, it is not advised to proactively wear noise-cancelling earphones or sunglasses when you’re NOT in the middle of an episode. This may gradually increase your sensitivity to these triggers.

4)  Vestibular Rehabilitation and Physical Therapy

Vestibular rehabilitation therapy involves accurately assessing your vestibular dysfunction and providing treatment through advice and education, and a specific exercise prescription. Connecting with a qualified vestibular physiotherapist can provide you with the exercises and tools necessary to gradually reduce your sensitivity to some triggers. It can reduce how often you have an attack as well as decreasing the severity of your symptoms when an attack occurs. Physiotherapy is one of the most effective tools for long-term success in the management of vestibular migraine. Click here to learn more about Vestibular Rehabilitation Therapy.

 

Can vestibular migraine be cured?

No one can determine how long vestibular migraines can last. These are typically chronic issues that usually stay with a patient for years. However, the pattern and frequency of attacks do fluctuate, with some experiencing an increase in attacks over years, and others showing a decline in attacks and severity.

It is difficult to predict how the vestibular migraine patterns will change in any given person. However, when this condition is accurately diagnosed and the proper treatments are undertaken, the majority of patients show significant improvement. And in some cases, this condition can spontaneously diminish until it disappears.

Though vestibular migraines are one of the more common causes of dizziness, the current research is surprisingly sparse. Future research is clearly necessary to help diagnose and treat this condition more effectively.

 

Vestibular Migraine Treatment Near Me

It’s commonly asked who treats vestibular migraines. The best outcomes involve a team approach in the management of this condition, including vestibular physiotherapists, neurologists, otolaryngologists, and family physicians among other healthcare professionals.

Cornerstone Physiotherapy has clinicians who are experienced in treating vestibular migraine at our clinics located in Toronto, North York, Burlington and Markham. We offer free phone consults if you’re unsure that your condition is appropriate for our physiotherapists. Contact us today to learn more or to book an appointment.