Updated: April 16, 2018.
Migraine attacks that occur with dizziness, light-headedness or vertigo may be vestibular migraine.
You could be sitting down and suddenly you feel like your spinning where you sit. You could be walking down the corridor and lose your balance. Or you moved quickly and feel unsteady for an extended period of time. Is it all related?
- 1 What is Vestibular Migraine?
- 2 What are the symptoms of vestibular migraine?
- 3 What is the official diagnosis criteria?
- 4 How long does it last?
- 5 Who experiences Vestibular Migraine?
- 6 Why does vertigo occur in some, but not all people with migraines?
- 7 What triggers Vestibular Migraine?
- 8 How to prevent Vestibular Migraine?
- 9 Vestibular rehabilitation
- 10 Are there acute treatments for severe vertigo or dizziness?
- 11 Are there any other disorders associated with vestibular migraine?
What is Vestibular Migraine?
Vestibular migraine is a migraine attack which occurs with dizziness, vertigo or imbalance.
Vestibular migraine (VM) may also be called migrainous vertigo, migraine-associated vertigo or migraine-related vestibulopathy.
The International Classification of Headache Disorders 3rd Edition (ICHD III) recognizes VM as an “episodic syndrome that may be associated with migraine”. It is currently listed in the appendix of the ICHD-III which means that if more evidence emerges it may be listed as an official migraine classification in the future.
In some cases, episodes may occur without the migraine head pain itself and can be very disrupting for an individual.
What are the symptoms of vestibular migraine?
The vestibular system involves the inner ear which contributes towards our sense of balance, spatial orientation and movement. Problems that arise with the vestibular system commonly result in vertigo, dizziness or imbalance.
The ICHD-III outlines the following set of vestibular symptoms associated with vestibular migraine (1):
- Spontaneous vertigo. Including both internal vertigo; the false feeling that your body is moving, and external vertigo; the false feeling that your external environment is spinning or flowing.
- Positional vertigo. Occurring after a change in head position.
- Visually induced vertigo. Caused by the movement of something visually complex or large.
- Head motion-induced vertigo. Due to movement of the head.
- Head motion-induced dizziness with nausea. Refers to dizziness that feels like spatial disorientation.
Auditory symptoms, including hearing loss, tinnitus, and aural pressure have been reported in up to 38% patients with vestibular migraine. (2)
What is the official diagnosis criteria?
Diagnostic criteria according to the International Classification of Headache Disorders (ICHD-3):
A) At least five episodes fulfilling criteria C and D
B) A current or past history of Migraine without aura or Migraine with aura
C) Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours
D) At least half of episodes are associated with at least one of the following three migrainous features:
- headache with at least two of the following four characteristics:
- unilateral location
- pulsating quality
- mod erate or severe intensity
- aggravation by routine physical activity
- photophobia and phonophobia
- visual aura
E) Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.
Vestibular symptoms are defined by the Bárány Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of A1.6.6 Vestibular migraine, include:
a) spontaneous vertigo:
– internal vertigo (a false sensation of self-motion);
– external vertigo (a false sensation that the visual surround is spinning or flowing);
b) positional vertigo, occurring after a change of head position;
c) visually-induced vertigo, triggered by a complex or large moving visual stimulus;
d) head motion-induced vertigo, occurring during head motion;
e) head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
How long does it last?
The duration of attacks is highly variable. Episodes of dizziness can last a few seconds up to a few days (2).
- About 30% of patients have episodes lasting minutes.
- 30% have attacks for hours.
- Another 30% have attacks over several days.
- The remaining 10% have attacks lasting only seconds, which tend to occur repeatedly during head motion, visual stimulation, or after changes of head position. (4)
There is a small percentage of people who have debilitating daily vertigo that can be an extremely disruptive experience.
Who experiences Vestibular Migraine?
40% to 70% of those with migraine will experience vertigo at some point but not necessarily with every attack. (2)
In most cases migraines occur earlier in life than VM (2). VM also arises more often in women than in men.
It is surprisingly common in migraine. Up to 10.3% of patients described VM in a Chinese neurological department. (1) This is also the type of migraine which musician Janet Jackson experiences.
Why does vertigo occur in some, but not all people with migraines?
The mechanism of VM is not fully understood. There may be interactions between pain and balance pathways in the brain during attacks of VM that do not occur during typical migraine attacks. Any abnormalities in the inner ear of VM sufferers may also be causing balance problems.
What triggers Vestibular Migraine?
The most common causes of an acute attack are often similar to those which trigger other migraine attacks. These include:
- Insufficient or inconsistent sleep
- Excessive stress
- Specific foods (or trigger foods which may be specific to the individual)
- Sensory stimuli
- bright or scintillating lights
- intense smells
- intense noise
- Lack of exercise
Looking at complex patterns, bright computer screens, smelling wet paint, eating chocolate, not getting enough quality sleep, running late to an important appointment or drinking champagne are all potential triggers.
How to prevent Vestibular Migraine?
In many VM patients, the attacks are severe, long and frequent enough to warrant a preventative migraine treatment. This may include topiramate (click to here to learn more about this treatment) or divalproex sodium or other migraine preventatives.
There are also several other treatments that might help specifically vestibular migraine.
In an interview at the 2017 Migraine World Summit, the Director of Headache at the Mayo Clinic, Dr. David Dodick shared some of these:
To see a 7-min video preview of his interview, visit the Migraine World Summit here >>
The treatments listed above can be helpful if taken regularly to prevent attacks. Hence the classification of prevention treatments. However for someone with a severe case of migraine vertigo it may not be enough. Sometimes Vestibular rehabilitation can be helpful.
These are exercises that are usually conducted by a physical therapist or a therapist who specializes in vestibular therapy.
The patient is given a set of exercises which they learn and then practice at home. They are designed to reduce dizziness-related issues and improve balance.
The exercises are often referred to as habituation exercises. That means the more you practice, the less severe the symptoms become. In a gentle and light way, the symptom is provoked repeatedly until they dissipate over time.
Dr. Dodick explains in the interview:
Balance training exercises can also be helpful for those who may have persistent dizziness or vertigo issues.
Are there acute treatments for severe vertigo or dizziness?
Due to a lack of research and clinical trials for VM patients, specific treatment protocols have not yet been developed for Vestibular Migraine patients. This area is in need for further research and development.
Those with VM are treated similarly to the standard migraine headaches. Acute medications such as the triptans (eg Sumatriptan) or anti-inflammatories may be helpful for treating individual attacks.(7)
In severe cases which do not respond to the above treatments there are further options to consider. The class of medications called the neuroleptics or dopamine antagonist such as prochlorperazine and other such treatments can be effective. Benzodiazepines such as lorazepam, clonazepam can also be helpful for an acute attack of vertigo.
In addition to the above, antihistamines are also worth considering according to Dr. Dodick.
Are there any other disorders associated with vestibular migraine?
Those with VM are more likely to suffer from motion sickness. (5)
There is also link between anxiety and VM. (5) This may not be a surprise as constant vertigo, light-headedness or dizziness is an unsettling reminder that something is wrong. Without effective treatment it is not difficult to imagine how this may cause some level of worry or anxiety.
Meniere’s Disease which is an inner ear disorder characterized by tinnitus (ringing in the ears), hearing loss, dizziness and ear pressure may also be linked with VM. (6) These two conditions have very similar symptoms. The key difference is the hearing loss in Meniere’s Disease is severe whilst in VM is it generally temporary.
Let me know in the comments below, have you ever had some kind of lightheadedness, dizziness or vertigo with your migraine attacks?
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1) Headache Classification Subcommittee of the International Headache Society. The international classification of headache disorders: 3rd edition. Cephalalgia. 2013;33:629-808.
2) Lempert T. Vestibular Migraine. Semin in Neurol. 2013;33(3):212-218.
3) Hsu LC, Wang SJ, Fuh JL. Prevalence and impact of migrainous vertigo in mid-life women: a community-based study. Cephalalgia 2011; 31 (1) 77-83
4) Bisdorff A, Von Brevern M, Lempert T, Newman-Toker DE. Classification of vestibular symptoms: towards an international classification of vestibular disorders. J Vestib Res 2009; 19 (1-2) 1-13
5) Lempert T, Neuhauser H (March 2009). “Epidemiology of vertigo, migraine and vestibular migraine”. J. Neurol.256 (3): 333–8. doi:10.1007/s00415-009-0149-2.PMID 19225823.
6) Cha YH, Kane MJ, Baloh RW. Familial clustering of migraine, episodic vertigo, and Ménière’s disease. Otol Neurotol 2008; 29 (1) 93-96
7) Fotuhi M, Glaun B, Quan SY, Sofare T (May 2009). “Vestibular migraine: a critical review of treatment trials”. J. Neurol. 256 (5): 711–6. doi:10.1007/s00415-009-5050-5. PMID 19252785.
I’ve suffered with Migraines for 23 years now and after reading your article on vestibular migraine, I believe I suffer with it, I get vertigo if I get up too fast , in stormy weather and watching a video that the camera is moving really fast, I’m on Verapamil which helps or is there something else I can try.
I have had chronic intractable migraines for almost 30 years. They have now gotten to the point where 90% of the time triptans don’t work and I either suffer until it is gone or go to the ER to get the cocktail. My last step is Botox, waiting to see if my insurance will approve it. But 5 weeks ago I started having unexplainable vertigo and hearing a static sound. Every time it happens it lasts like 36 hours at varying intensity, but has only happened with an actual migraine once. We ruled out stroke and MS through a MRI. All that is left is Menieres and VM. So is this more likely VM?
Only your doctor can diagnose you. It is tricky as symptoms can overlap. I would prioritize seeing a specialist to help you get an accurate diagnosis. That will inform the best treatment approach.
I have had daily varying degrees of being dizzy, lightheaded and vertigo since October 2014, after a chiropractic adjustment. At the time of the adjustment the chiropractor did not realize I had severe cervical disc degeneration, arthritis and spurs. Since October 2014, I have seen multiple doctors and have had an MRI, MRA, CT Scan, medications sumatriptan, amitrityline, physical therapy, laser therapy, prolozone injections, steroid injections, radio frequency ablation, one round of Botox and acupuncture. After listening to Dr. Dodick, I realized how difficult Vestibular migraines are to treat and I have a referral to the Mayo Clinic to see him. Thanks to this site I have learned a tremendous amount about migraines and will never give up hope, one day I will be migraine controlled and not have the vertigo and dizziness anymore.
You have a great attitude Monica and thank you for the kind words. I’m so glad you’ve got an appointment with Dr Dodick. He truly is a world leading expert. You’ll be in good hands there.
I have definitely had this for several years. I just found a new neurologist that was able to explain my symptoms and the reason this was happening. For several years I have been a nervous wreck because I didn’t understand what was happening. It’s a very scary feeling. If only there was a good treatment for this. I also have 13 lesions on my brain from migraines!
Hey Tina, there is a great interview with David Dodick in 2017 at the Migraine World Summit which covers some great options for patients. This year (2018) I know that there will be some discussion about the significance or insignificance of white matter lesions that might appear in scans in those with migraine.
Hello, I have recently started suffering from vertigo, dizziness, nausea, brain fog (October 2017). I have a history of migraines since I was 15. Can these symptoms be reversed? I am a competitive bodybuilder and have an online business. It is hard to function and work on my goals. Can the condition be completely treated, so I am at a 100%. Thank you very much.
Also, is there a good place where I can read more about migrainous vertigo, tips and advice
It can be treated. I think it will depend on the individual patient and case as to whether you can get back to 100%.
You can see a preview of Dr David Dodick’s interview at the Migraine World Summit here: https://www.migraineworldsummit.com/public-david-dodick/
Further reading could be to utilise Google Scholar and search for vestibular migraine research and read through some of the peer reviewed research. That’s what formed much of this article.
I hope that helps.
I have recently been diagnosed with VM
After months of wrong diagnosis’
I tried Topamax that was Aweful
I am extremely sensitive to medications
I cleaned out my diet and was hoping that would help
But no such luck
I try to exercise but it exasperated the dizzy more
I am trying acupuncture and started taking migravent
I also take Zoloft for many year the dr recommended increasing it
I didn’t see any difference in the dizzy
Vestibular exercise helps but doesn’t last
I am so exhausted by this
I would appreciate
Everything I know and seen from the research I’ve put into this article.
The only other suggestion I’d have is to watch Dr David Dodick in his 2017 interview at the Migraine World Summit which was well received by those with VM.
You can view a preview here (but you need to order a copy to view all of the interview): https://www.migraineworldsummit.com/public-david-dodick/
You mention the significance of white matter lesions seen in MRI and migraines ? Can you elaborate ? I have some seen during neuro workup for Vestibular Migraines !
Thank you ,
They are common in migraine and not usually anything to worry about. It’s not a sign or stroke or early dementia like we all fear… but they are there. I’ll let Dr William Young explain in more detail during the 2018 Migraine World Summit in April. That’s the talk that covers this area.
After weeks that became months of chronic dizziness and mild nausea, I was finally diagnosed with vestibular migraines. Verapamil has helped me to the point of being able to have a fairly normal life. I am still sometimes triggered by certain lights, loud chaotic events (no more rock concerts) and who knows what.
Glad to hear you have found some relief Susan. Thank you for sharing.
I have just been diagnosed with VM after 8 years of incorrect diagnosis of another vestibular condition. I am still sceptical as I have received so many incorrect diagnosis at this stage, and I am wondering how VM is typically diagnosed? What are the usual criteria for this illness?
This is a great question Marian, so important in fact that I’ve updated the article to include a whole new section on the diagnosis. Please check above and you’ll find a detailed response which should help. Great question!
I was recently diagnosed with Hypothyroidism and assumed my dizziness stemmed from that, but it only became worse where I was unable to work or even drive. My Endocrinologist didn’t know what was causing it, so I’ve also seen a Cardiologist, Gynecologist, ENT, Dentist, Neurosurgeon and finally an ENT/Neurotologist who diagnosed it as MAV just 2 weeks ago. I experience daily vertigo and am about to go up to the next dosage of Topomax. It’s helped with the pressure in my head, but not the dizziness though sometimes it is less severe.
I wasn’t convinced this is what I had because I found it odd after having a root canal, the headache and dizziness became so much more intense, yet on the opposite side of my head. The doctor thought it could possibly be another trigger for me though. And I do have a history of migraine from my twenties.
Reading your article shed more light on my battle with MAV and I’m hopeful this medication will work as well as any rehabilitation I may need. Very interesting. .thank you!
My pleasure Marika, I’m glad this article helped. Good luck with the treatment and prevention.
I am 54 years old and have always had motion sickness, severe vertigo, associated nausea, fatigue, anxiety, soft tissue pain, and aura. In the last two-years, my symptoms have gotten worse. I have tried "conventional treatments" through a neurologist. I have NOT been able to find relief. The doctors I have visited are stumped with what treatment(s) would be effective for me. I have an appointment with a new neurologist whose internship was at a vestibular center in Texas. What tests are available for correct diagnosis? What treatments might help me, so that I can share these possibilities with him?
Hi Tammy, everything I know about this topic I’ve put in the article. It refers to treatments and exercises that have been shown to be effective. Good luck with your new appointment, it sounds promising with their vestibular background.
I was diagnosed with VM about 4 months ago. The side effects of preventative meds are not worth it to me. Dizziness or a feeling of being off balance is my major issue, not the migraine. I have started Vestibular rehab and am hoping this works. Any advice is appreciated.
Hi Shelly, a new treatment has come out that is available to those with chronic migraine. They are the CGRP antibodies. Find out more information here: https://migrainepal.com/cgrp-antibodies-migraine/
Hi Carl. I wonder if you know of any treatments that are not traditional medication please?
Hi Anthony, yes there are over 100 natural treatments that may be used to assist with migraine either preventively or for an acute attack. It all depends on the individual and their condition. The Migraine World Summit has the largest directory of these treatments. A couple of examples for prevention to complement your treatment regime include consistent quality sleep, diet with minimally processed foods (see migraine diet), regular exercise and regular relaxation. For an acute attack lots of people use a dark quiet room, ice and ginger powder at the first signs of an attack. All of the above is natural.
I am 34 years old and started with vestibular migraines this may. They started out as small episodes of dizziness and lightheadedness and turned into full.blown vertigo and then into these attacks of severe dizziness, motionsickness, visual disturbances such as spots dots floaters and visual static, nausea, head pains, extreme fatique,diahrrea, eye pain, sensitivity to noises, walking problems, balance issues and speech problems, trouble concentrating. I have had migraines in the past but nothing like this. This is awful. I seen a neurologist, balance specialist, migraine specialist , psychologist, chiropractor and accupuncture. I am on amovig, relpax, mirgirelief, magnesium, butterbur, milkthistle, lexapro, and compazine. All this was helping but i started back to work after being off 3 months due to debilitating symptoms daily. Now I am back to work, all of it is starting to flare up again. More doctors appointments. I am extremely frustrated cause these symptoms happen out of nowhere. I am doing relaxation and meditation and stressing less. It’s seems physical activity is flaring it up.
That does sound frustrating Heather, sorry to hear that. You seem to be doing many of the right things for migraine prevention. You can use migraine preventives for vestibular migraine and they have been shown to be effective. There is also vestibular rehabilitation and more specific treatments that are mentioned in this article. I hope it has helped. Focus on prevention.
I began having motion sickness in October of 2019. After driving for an extended period of time, I would get out of the car feeling dizzy, imbalanced, and nauseous. This feeling lasted for hours. I had an MRI, went to an ENT, and neurologist before I saw your interview with Dr. T at the Migraine Summit. Luckily I was able to get a diagnosis of VM from him. Hopefully I am on the road to recovery.
Hi Matt, I’m so glad you found some answers and an accurate diagnosis! Thank you for letting me know. Good luck and take care.
Hi Carl, thank you so much for the article! I was just diagnosed today with VM. It was after a major auto accident 10 years ago that I first began experiencing dizzy spells. Presently, they are attacks with nausea, vomiting, and vision disturbances that last up to a week(s). I remain hopeful after years of misdiagnosis.
Hi Claudia, I’m glad this article has helped. The correct diagnosis is a big step towards finding the right treatment. Good luck!
It’s a very good article.
I have MAV for 6 years starting with a nasty ear infection. Doctor thought I had a stroke at first.
Cat scan did not show anything.
The Epley Manoeuvre helped the vertigo but had it done 3 times before it worked. Balance was still an issue. I did 4 months of physio where I had to learn to walk again. The exercises helped but you have to keep doing them for quite a while to see results. Not perfect but better.
Tried acupuncture for over a year not much help for me. Regular massage and pulsed biofeedback have really helped.
But don’t give up. It takes time. I still get migraines but they are not as severe but still 8 to 12 a month.
I do take Propanolol and Amitryptaline which help. I also take magnesium, Butterbur and Melatonin.
Some days are ok but lots are not. I can still play with my grandkids but have to carefully space the days apart.
Triggers are the same: loud noise, bright lights, MSG, chocolate, moving my head a lot (example when I am sitting with friends and have to move my head from side to side when they speak.)
Even house work has to be spaced out and working in my flower beds is reduced to 25 min. a day.
For years my head felt stuffed and brain fog was terrible. I missed so much time I would normally spend with family and friends.
The neurologist said just to try different meds. EMT could not help the tinnitus. Left ear steady tone and right ear can be any kind of music, echo etc.
Keep going and keep trying. Only you can find what can help.
I have migraine associated vertigo for six years. It was very difficult at the beginning to get a diagnosis. At first my doctor thought it might be a stroke and sent me for a CT scan which was normal.
I saw an ENT because of hearing problems and he said it was caused by an ear infection. Vertigo was better after the Epley Manouver done by my doctor finally the 3rd time.
Went for vestibular exercises to physio for 4 months to help me walk again.
Migraine with Aura very painful.
Tried acupuncture, massage and pulsed biofeedback. Tried different meds now on Propanolol and Amitriptyline.
It’s really tough. I miss so much still 8-10 migraines a month down from 10-15.
It’s good to read about others trying everything to get better.