Vestibular Migraines: The Hard-to-Diagnose Headache
The dizzy migraine
“Vestibular migraine is a migraine variant. These patients have symptoms that are a result of dysfunction of their balance system,” explains Adrian Priesol, MD, an otoneurologist in Boston who specializes in managing patients with dizziness and balance disorders.
Migraine is a neurological disorder characterized by moderate to severe head pain, which could be on one side of the head or both. Some people also experience nausea or vomiting and sensitivity to light, noise, or smells.
According to the American Migraine Foundation, at least 39 million Americans are living with migraines. It is well-known that a subset of people with migraines experience aura—visual disturbances including seeing spots, zig-zags, or flashes.
(Here’s what to know about ocular migraine.)
Recently, researchers have recognized that some migraine patients experience symptoms related to their vestibular, or balance, system.
“What we have come to learn over the last decade or so is that probably half the people I see who come in with dizziness have an underlying migraine disorder that’s causing their problem,” says Dennis Fitzgerald, MD, an otolaryngologist in Philadelphia who is on the board of directors for the Vestibular Disorders Association.
It’s unclear how many people experience vestibular migraine, although some studies, like this 2016 study in Behavioural Neurology, suggest it’s about 1 percent of the general population and 10 percent of people with migraines.
Vestibular migraine symptoms
People with vestibular migraines report a range of symptoms.
“They can have true vertigo where the room is spinning or they can have a rocking sensation or lightheadedness,” says Dr. Priesol.
“And a lot of patients develop what we call visual vertigo, where visual stimulation, like seeing things moving on computer screens, will trigger dizziness in them or make their dizziness worse.” These episodes can last from seconds to several days.
Some patients experience other ear symptoms, like ear pain and ear fullness and pressure, says Dr. Fitzgerald. These symptoms can be before or during a headache although some patients never get a headache and still have a vestibular migraine.
“This can make it a little bit tricky to diagnose because it doesn’t have to occur along with a typical migraine headache,” says Dr. Priesol.
Causes of vestibular migraine
It’s unclear what causes people to have a migraine, but genetics and the environment play a role.
“You’re actually born with the genetics that lead to migraine symptoms, which means that you’re what we call a “migraineur” your whole life,” says Dr. Fitzgerald.
But while you’re a migraineur for life, the symptoms of your condition can change over time. For example, you could have migraine headaches throughout your life but the dizziness symptoms only show up later on.
How is vestibular migraine diagnosed?
Vestibular migraine can be tricky to diagnose. There is no specific test—and when most people go to the doctor with complaints of dizziness they don’t immediately think to tell the doctor they also get migraines, says Dr. Fitzgerald.
“It’s also a great mimicker,” says Dr. Priesol. “It can cause symptoms that are very similar to a lot of inner ear balance problems or other neurologic problems.”
A vestibular migraine diagnosis is made by ruling out other conditions and/or seeing if a patient responds to migraine treatment. If the dizziness seems to be triggered by diet, weather fluctuations, or hormones that’s another clue that they may be part of a migraine disorder, says Dr. Fitzgerald.
It’s important, though, if a patient has a history of migraine and complains of dizziness, not to automatically assume their dizziness is caused by migraine.
“Migraine itself is very common,” says Dr. Priesol. “It could be a coincidence and there could be some inner ear pathology that’s causing their dizziness.”
Treating vestibular migraine
For the most part, vestibular migraine is treated the same as more typical migraines—by avoiding triggers, and by taking medication and supplements.
For some people, certain foods can trigger a migraine. These can include:
- alcohol, particularly red wine
- processed meats
- artificial sweeteners like aspartame
- dairy products, especially aged cheese
- food that contains the food additive monosodium glutamate (MSG)
“We’ll often recommend a migraine elimination diet,” says Dr. Priesol, “Which is basically a guide of avoiding certain foods. I’ll have my patients try that for a month or two and see if we can get these symptoms to calm down with that.”
Irregular sleep schedule
Changes to your sleep schedule can trigger a migraine. The American Migraine Foundation recommends going to sleep and waking up at the same time every day and aiming for seven to eight hours of sleep.
Stress is a big trigger of migraines. “Learning to improve your relaxation responses, with things like mind and body programs, can be very helpful in minimizing migraine symptoms,” says Dr. Priesol.
Some triggers, like hormone fluctuations and weather changes, can be hard to manage or control, acknowledges Dr. Fitzgerald. In some cases, if other lifestyle changes don’t improve symptoms, you may need preventative medications.
Medications and supplements
Medications to prevent migraine
If lifestyle changes and trigger avoidance doesn’t get vestibular migraine symptoms under control, then doctors will start looking at medications to prevent a vestibular migraine. These are the same medications used for prevention in regular migraines and could include beta-blockers or calcium channel blockers, or older-generation antidepressants.
“The nice thing about the preventative medication is you don’t need to take them forever. One way of thinking about it is that they reset the brain chemistry, and once that’s happened and the person’s symptoms become infrequent, it can be tapered off,” says Dr. Priesol.
(These are the migraine remedies proven to work.)
When you’re having a vertigo attack, typical migraine medications that target the pain, like ibuprofen, acetaminophen, and triptans, aren’t helpful for the dizziness symptoms. Although they can still be beneficial if you have a headache with your dizziness.
To target the dizzy symptoms, doctors might prescribe or recommend meclizine or dimenhydrinate, which are antihistamines used to treat motion sickness and dizziness.
Certain supplements and herbs, like magnesium, vitamin B2, coenzyme Q10, and butterbur are thought to help prevent migraine, according to Dr. Fitzgerald.
A vestibular migraine can be challenging to diagnose and treat. Currently, there is no cure, but there are preventative medications that can help. However, these medications may not always be accessible to every patient.
If you’re experiencing dizziness, it’s always best to check in with your doctor to see what might be going on. But don’t hesitate to ask about vestibular migraine. “It’s underdiagnosed and it’s very treatable,” says Dr. Priesol. “Go see a doctor to get a proper assessment. There are good treatments out there, and you don’t have to live with it.”
Next, here’s how to identify the warning signs a migraine is coming.
- American Migraine Foundation: "What is Migraine"
- American Migraine Foundation: "Migraine Aura without Headache"
- Behavioural Neurology: "Recent Advances in the Understanding of Vestibular Migraine"
- International Headache Society: "IHS Classification ICHD-3"
- American Migraine Foundation: "Top 10 Migraine Triggers and How to Deal with Them"
- Adrian Priesol, MD, instructor in otolaryngology–head and neck surgery, part-time, Harvard Medical School and an otoneurologist in Boston
- Dennis Fitzgerald, MD, assistant professor at Thomas Jefferson University Sidney Kimmel Medical College and an otolaryngologist in Philadelphia
- American Migraine Foundation: "Diet and Headache Control"