Vestibular migraine
What is vestibular migraine?
Vestibular migraine is a neurological condition that causes episodes of dizziness, vertigo, imbalance, and/or sensitivity to motion. These vestibular symptoms can occur with or without headache, and happen in people with a history of other migraine symptoms. Terms that were formerly used to describe this condition include: migraine-associated vertigo, migraine-associated dizziness, migraine-related vestibulopathy, and migrainous vertigo.
Migraine is not just a headache! Approximately 40% of people with migraine experience some associated vestibular symptoms before, during, after, or separate from a migraine attack. Some people with vestibular migraine experience vestibular symptoms, without any headache or head pain.
Symptoms of vestibular migraine may include spontaneous vertigo, vertigo with position change, imbalance, sensitivity to head motion, visual sensitivity, and dizziness (for example lightheadedness, spatial disorientation, or rocking).
Diagnostic criteria for vestibular migraine
The Bárány Society and International Headache Society have outlined specific standards to diagnose vestibular migraine.
Vestibular migraine
At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
One or more migraine features with at least 50% of the vestibular episodes:
Headache with at least two of the following characteristics: one sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity
Photophobia and phonophobia
Visual aura
Not better accounted for by another vestibular or ICHD diagnosis
Probable vestibular migraine
At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
Migraine history or migraine features during the episodes
Not better accounted for by another vestibular or ICHD diagnosis
For the purposes of the diagnostic criteria for vestibular migraine, vestibular symptoms include:
Spontaneous vertigo including
Internal vertigo, a false sensation of self motion
External vertigo, a false sensation that the visual surround is spinning or flowing
Positional vertigo, occurring after a change of head position
Visually-induced vertigo, triggered by a complex or large moving visual stimulus
Head motion-induced vertigo, occurring during head motion
Head motion-induced dizziness with nausea - with dizziness characterised by a sensation of disturbed spatial orientation
Clinical examination may be completely normal between migraine attacks (which is known as the interictal phase).
What causes vestibular migraine?
Migraine is a neurological condition. The exact mechanism is not clearly understood, but migraine involves neurological and vascular activation in the brain. There is a wave of brain activity called cortical spreading depression, which changes nerve and blood vessel function and is believed to cause migraine auras and to activate pain pathways.
Vestibular migraine is estimated to affect 1 to 3% of the general population. It appears to be more common in women, and there may be a hereditary or genetic component. The average age of onset is around 40 years of age. There seems to be a lower age of onset for people with a family history of migraine or vertigo. Vestibular migraine is often associated with a history of motion sickness.
Is it VM or could it be something else?
Other conditions can cause symptoms similar to vestibular migraine. Fluctuating symptoms, and/or symptoms triggered by head, body, or visual motion can also be caused by Persistent Postural Perceptual Dizziness (PPPD) or Mal de Débarquement Syndrome (MDDS). Symptoms with head position changes or positional vertigo can be caused by Benign Paroxysmal Positional Vertigo (BPPV) or much more rarely by central positional nystagmus. Episodes of spontaneous vertigo can also be caused by Meniere’s disease, recurrent peripheral vestibulopathy, or transient ischemic attacks (TIA or ‘mini-stroke’).
It is possible to have more than one condition contributing to symptoms, for example you could have both vestibular migraine and PPPD, or you could have BPPV and vestibular migraine. It is also worth noting that BPPV seems to be more common in people with migraines and in people with Meniere’s disease. This makes it very important to have a comprehensive assessment with a knowledgeable health care provider who can follow you over time, and your treatment may require a team-based approach.
Medical treatments for VM
You may need to see a neurologist, otolaryngologist, neurotologist, and/or headache specialist for medical management of vestibular migraine. Your doctor may recommend medications to help your symptoms. Medications for vestibular migraine are based on treatment protocols for migraine headache.
Medications can be used to decrease the intensity and duration of migraines when they occur. These are referred to as migraine abortive medications, and examples include triptans, nonsteroidal anti-inflammatories, and gepants. These are usually taken at the start of a migraine episode.
Medications can also be used to try to decrease the frequency of migraine episodes or break the cycle of chronic migraines. These are referred to as migraine preventative or prophylactic medications, and examples include amitriptyline or topiramate. These medications are usually taken daily. SNRI/SSRI medications are also used for migraine prevention, particularly for people who also experience anxiety, visual motion sensitivity, and/or chronic vestibular symptoms (e.g. venlafaxine). A newer option are CGRP monoclonal antibodies, which are given by injection. As always, talk to your doctor and pharmacist before taking any medications.
There is some research on certain supplements or nutraceuticals for migraine, for example magnesium citrate, coenzyme Q10, or riboflavin (vitamin B2). It is important to discuss the correct dose and potential side effects with your doctor and pharmacist before taking any supplements.
Botox injections may be used to treat chronic migraine headaches, particularly when medications have not helped. It is used for some people with vestibular migraine particularly when they do also experience headaches. Scientific evidence for Botox in vestibular migraine is still emerging but appears promising.
Non-invasive nerve stimulation devices are a newer treatment for migraine. These devices use electrodes to stimulate the vagus nerve or trigeminal nerve. Emerging research suggests that vagus nerve stimulation may help vestibular migraine, particularly to treat acute attacks.
Non-medication treatment for VM
Lifestyle changes can help manage and improve control of migraines. Many people find that identifying and minimizing triggers can decrease the frequency of episodes. Each person’s triggers are different, so it can take some time to track and identify potential patterns.
Improving sleep > sleep deprivation can be a migraine trigger for some people, and keeping a regular bedtime and wake time can help
Dietary triggers > many people find that certain foods impact their migraines including caffeinated beverages like coffee or tea, foods containing nitrates and nitrites, aged cheeses, cured meats, and alcohol; some people find that eating protein at breakfast can help prevent migraines
Staying hydrated > many people find dehydration can trigger migraines
Stress can be a trigger for migraine attacks in some people. Treatment for anxiety and psychological counselling can also be important components to your treatment plan. Mindfulness, breathing exercises, and relaxation strategies can be helpful to manage stress and cope with vestibular symptoms.
Physical activity can be very helpful for managing migraines. General low impact exercise has many benefits, and can decrease vestibular migraine frequency and intensity. Doing too much all at once or increasing your activity level too quickly can be a trigger for some people, so it can help to have a physiotherapist provide guidance. Physical activities involving head/body turns, bending, position changes, or busy environments can provoke symptoms for some people, and a physiotherapist experienced in vestibular rehab can help you modify activities if needed and come up with an exercise plan.
Vestibular rehab for vestibular migraine
Vestibular rehab physiotherapy can help to address specific vestibular symptoms, particularly imbalance and symptoms triggered by head movement, body movement, or visual stimuli.
Vestibular rehabilitation exercises are usually performed between acute attacks, and are personalized to your specific symptoms and triggers. These exercises may include balance training to address symptoms of imbalance and over-reliance on visual information for balance (called visual dependence). Your rehab program may also include habituation exercises to work to gradually increase your tolerance to head and body movement, or to visually complex environments or moving visual stimuli. Your home exercise program may also include a walking program, strengthening exercises, or other low impact exercise focused on achieving your goals.
A vestibular physiotherapist can also provide strategies to help manage and decrease the frequency or intensity of episodes like tracking triggers, supporting lifestyle changes, and creating a plan to get you back to your usual activities.
Want more information or to see if vestibular rehab could help you? Call us to talk to one of our physiotherapists.
Thumbnail image source: wellcomecollection.org
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