The Migraine Balancing Act: Vertigo & Vestibular Migraine

[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 maybe you simply moved too quickly and feel unsteady for an extended period of time. Is it all related?

What is Vestibular Migraine?

Vestibular Migraine (Vertigo)

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:

  1. headache with at least two of the following four characteristics:
    • unilateral location
    • pulsating quality
    • mod erate or severe intensity
    • aggravation by routine physical activity
  2. photophobia and phonophobia
  3. visual aura

 

E) Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.

Notes

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
  • Menstruation
  • 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.

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:

There’s a medication called Acetazolamide. It’s an old medication, but we use that for patients with vestibular migraine. There’s another medication called Verapamil. Verapamil is a calcium channel blocker, sometimes used for patients with high blood pressure. But Verapamil, we think, is probably more effective for vestibular migraine and some other unusual migraines that I think we may talk about, than it is for typical migraine.

Another medication which unfortunately we don’t have in the United States, but is available in many countries around the world, is a medication called Flunarizine. It too is a calcium channel blocker, but it can be very effective for the vertigo associated with migraines.
— Dr. David Dodick, Mayo Clinic Headache Director

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.

Vestibular rehabilitation 

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: 

The brain has amazing capacity to adapt to either an injury, or to abnormal function of a certain pathway. In vestibular migraine, we don’t think that the vestibular pathway is injured necessarily, but it’s not functioning properly. This is in an effort to try to get other parts of the brain to adapt or compensate for that.

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 can appear very similiar with their 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 light headedness, dizziness or vertigo with your migraine attacks? I respond to every comment. 



Sources:

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.