For Healthcare Professionals:
Distinguishing between Menière's disease (MD) and vestibular migraine (VM) is one of the greatest challenges in daily clinical practice. A new large cohort study by Vosbeek et al. shows that while patient history remains the foundation, vHIT and caloric testing provide crucial pieces of the puzzle for the correct diagnosis — especially when symptoms overlap.
🔗 Vosbeek EGM, Seelen M, Vingerhoed AM, et al. Vestibular function tests are helpful in differentiating between Menière’s disease and vestibular migraine. Front Neurol. 2025;16:1569247. Published 2025 Aug 7.
The problem of overlapping symptoms
The study examined nearly 300 patients and confirms what clinicians often experience: symptoms are not always clearly distinguishable.
- Surprisingly: more than 65% of VM patients experienced at least one ear-related symptom during attacks (hearing loss, tinnitus, or ear pressure), which has traditionally been associated more with MD.
- Demographics: VM patients are on average younger (mean age 50 years) and much more often female (86%) than MD patients (mean age 60 years, 46% female).
The diagnostic power of vHIT and caloric testing
The study shows that objective vestibular function tests have a high predictive value (Positive Predictive Value, PPV) in distinguishing MD from VM:
- Video Head Impulse Test (vHIT) An abnormal vHIT (low gain + saccades) has a PPV of 81% for Menière’s disease. Therefore, if the test is abnormal, MD is highly likely.
- Caloric testing as a complement: Since vHIT can often be normal in MD (Negative Predictive Value only 36%), caloric testing is essential. In patients with a normal vHIT, caloric weakness with a PPV of 82% indicates MD .
- The New Threshold: The authors propose increasing the cut-off value for caloric unilateral weakness to 34%. This raises the diagnostic accuracy (PPV) for Menière’s disease to 90%.
Conflicting test results (vHIT-caloric mismatch)
A typical feature of Menière’s disease remains the divergence between tests: abnormal caloric testing despite a normal vHIT. This was observed in 56.5% of MD patients (compared with only 24.2% in VM). One possible explanation is dilation of the semicircular canals caused by endolymphatic hydrops, which primarily alters the response to thermal stimuli.
Conclusion for Practice
When patient history alone is not sufficient, vestibular testing provides important guidance for diagnosis:
If the vHIT is normal, caloric testing should definitely be performed. A unilateral weakness above 34% strongly suggests MD.
An abnormal vHIT makes the diagnosis of MD highly likely; caloric testing is often redundant in this case.
👉 Are you interested in a comprehensive further training in vestibular rehabilitation and want learn how to confidently interpret vHIT and caloric testing and optimally adapt treatment?
Current further education opportunities and course dates can be found in the IVRT Course search.
For Patients – Easy to Understand
Menière’s disease or migraine? Why ear specialist tests sre oo important
Vertigo attacks can have many causes. Menière's disease an inner ear disorder) and vestibular migraineare especially often confused. Because both conditions can cause very similar symptoms such as tinnitus or pressure in the ear, simply describing symptoms is sometimes not enough.
📄 Vosbeek EGM, Seelen M, Vingerhoed AM, et al. Vestibular function tests are helpful in differentiating between Menière’s disease and vestibular migraine. Front Neurol. 2025;16:1569247. Published 2025 Aug 7. doi:10.3389/fneur.2025.1569247
What the new study means for you:
- Symptoms can be misleading: Nearly two-thirds of migraine patients experience symptoms such as hearing loss or tinnitus, which were previously thought to occur only in Menière’s disease.
- Who is affected? The study shows that migraine patients are often younger (around 50 years old) and predominantly female. Menière’s patients are somewhat older on average (around 60 years old), and men and women are affected almost equally.
Why are two different tests necessary?
The “Video Head Impulse Test” (vHIT) using special goggles and caloric irrigation testing are often performed together. The study demonstrates how valuable the combination of both tests is:
- Video Head Impulse Test (vHIT): If this test is abnormal, the diagnosis of Menière’s disease is correct in 81 % of cases.
- Caloric testing: Because the vHIT can remain normal in some Menière’s patients, caloric testing is essential. If it shows a significant weakness (over 34%), diagnostic certainty for Menière’s disease rises to 90 %.
Why do the tests sometimes contradict each other?
It may happen that caloric testing shows weakness while the special goggles test produces completely normal results. This is not a device error!
- Typical for Menière’s disease: This discrepancy occurs in more than half of Menière’s patients.
- The reason: Increased pressure in the inner ear changes the shape of the semicircular canals. This affects the response to temperature during caloric testing much more than the response to rapid head movements during the goggle test.
What can you do?
If you suffer from recurring vertigo and the diagnosis remains unclear, specifically ask for both tests (vHIT and caloric testing). Only the combination of both results provides the full picture and helps determine the right treatment for you. Since treatment for migraine is very different from treatment for Menière’s disease, an accurate diagnosis saves time and unnecessary treatment attempts.
🎯 Our IVRT®-certified dizziness and vestibular therapists support you: Egal ob Menière oder Migräne – wir helfen ihnen mit einem gezielten Training, ihr Gleichgewicht zurückzugewinnen. Finden Sie spezialisierte KollegenInnen in unserer IVRT therapist search
