You're standing in the kitchen when the room suddenly starts to spin. Or you're sitting at your desk and a wave of dizziness hits, making the screen in front of you seem to tilt. Sometimes there's a headache. Sometimes there isn't. You've seen an audiologist, had inner ear tests, maybe even been told you have vertigo of unknown cause.
What you may actually have is vestibular migraine — the most common cause of spontaneous episodic vertigo in adults, and one of the most underdiagnosed neurological conditions worldwide.
What Is Vestibular Migraine?
Vestibular migraine is a subtype of migraine in which vestibular symptoms — dizziness, vertigo, imbalance, or motion sensitivity — are the primary or prominent feature, rather than (or in addition to) head pain. It is classified by the International Headache Society and the Bárány Society in their joint diagnostic criteria.
Up to 3% of the general population is estimated to have vestibular migraine, making it far more prevalent than conditions like Menière's disease that are more commonly diagnosed. Women are affected approximately 1.5–5 times more often than men, consistent with migraine generally.
Vestibular Migraine Symptoms
The vestibular symptoms in vestibular migraine are highly variable in duration, intensity, and character:
Vestibular symptoms (at least one required for diagnosis):
- Spontaneous vertigo — a false sense of spinning or movement, either internal (you feel like you're spinning) or external (the room appears to move)
- Positional vertigo — triggered by head movement, similar to BPPV but often longer-lasting
- Visually induced dizziness — triggered by moving visual environments (scrolling, crowds, traffic)
- Head motion-induced dizziness — dizziness or nausea triggered by turning the head
- Imbalance or unsteadiness — particularly during episodes
Associated migraine features (typically present with at least some episodes):
- Headache (throbbing, often one-sided, moderate to severe)
- Migraine aura — visual zigzags, blind spots, or sensory symptoms
- Sensitivity to light (photophobia) or sound (phonophobia)
- Nausea and vomiting
One of the diagnostic challenges is that headache and vestibular symptoms don't always occur together. Many patients have episodes of pure dizziness without any headache, and the connection to migraine isn't obvious without a careful history.
Duration of Episodes
Vestibular migraine episodes last anywhere from 5 minutes to 72 hours, which distinguishes it from BPPV (usually seconds) and Menière's disease (typically 20 minutes to 12 hours). The variability in duration is part of what makes vestibular migraine diagnostically challenging.
How Vestibular Migraine Is Diagnosed
There is no definitive test for vestibular migraine. Diagnosis is based on the clinical criteria established by the IHS and Bárány Society:
- At least 5 episodes of vestibular symptoms (moderate to severe)
- Current or prior history of migraine (with or without aura)
- At least 50% of vestibular episodes have at least one migraine feature (headache, photophobia, phonophobia, or visual aura)
- Not better explained by another vestibular or neurological diagnosis
A detailed migraine diary documenting both headache days and vestibular episodes — with their associated features — is one of the most useful tools for establishing this pattern and supporting a diagnosis. Tracking symptoms alongside potential triggers like hormonal changes, sleep disruption, and weather changes can also accelerate diagnosis.
Differential Diagnosis: What Vestibular Migraine Is Often Confused With
BPPV (Benign Paroxysmal Positional Vertigo):
BPPV causes brief vertigo (seconds) triggered by specific head positions. A positive Dix-Hallpike test confirms it. Vestibular migraine episodes are longer and not position-specific, though some overlap exists.
Menière's Disease:
Menière's causes episodic vertigo plus fluctuating hearing loss, tinnitus, and ear fullness — symptoms rarely seen in vestibular migraine. Some patients have features of both, termed "migrainous Menière's."
Persistent Postural-Perceptual Dizziness (PPPD):
PPPD is a chronic condition of persistent non-spinning dizziness that often develops after an acute vestibular event, including vestibular migraine. It requires different treatment.
Triggers for Vestibular Migraine
Vestibular migraine shares common migraine triggers but some are particularly prominent:
- Hormonal changes — many women notice vestibular episodes worsen perimenstrually
- Sleep disruption — both too much and too little sleep
- Barometric pressure changes — weather sensitivity is frequently reported
- Dietary triggers — caffeine withdrawal, alcohol, MSG
- Visual stimuli — busy patterns, screen use, bright light
- Stress — a major trigger, particularly for the vestibular component
Treatment of Vestibular Migraine
Treatment follows the same framework as other migraine types, with some additional considerations.
Acute treatment:
Triptans and anti-nausea medications (e.g., prochlorperazine, ondansetron) are used for acute episodes. Evidence for triptans specifically in vestibular migraine is growing, particularly for episodes that include headache. Benzodiazepines are sometimes used short-term for severe vestibular episodes but are not a long-term solution.
Preventive treatment:
For frequent or disabling episodes, preventive migraine therapy is recommended:
- Tricyclic antidepressants (nortriptyline, amitriptyline) — often first-line for vestibular migraine
- Beta-blockers (propranolol, metoprolol)
- Topiramate or valproate
- CGRP monoclonal antibodies — emerging evidence for vestibular migraine
- Venlafaxine — particularly used in vestibular migraine with anxiety
Vestibular rehabilitation:
For patients with ongoing imbalance or chronic dizziness between attacks, vestibular physiotherapy can significantly improve functional balance and reduce motion sensitivity over time.
Lifestyle:
Regular sleep, consistent meal timing, stress management, and trigger tracking form the foundation of vestibular migraine management. Many patients see significant improvement through lifestyle changes alone before medication is needed.
Getting a Diagnosis
If you have recurring dizziness, vertigo, or balance problems — especially with a personal or family history of migraine — ask your GP for a referral to a neurologist or specialist vestibular clinic. Bring a detailed symptom log showing the timing, duration, character, and associated features of each episode.
Track your vestibular migraine episodes alongside headache, aura, and trigger data with Migraine Trail — the free iOS app that helps you build the structured record your specialist needs.
