Vestibular disease
Vestibular migraine
This information is intended as a general introduction to this topic. As everyone is affected differently by balance and dizziness problems, you should speak to your doctor for individual advice.
For reasons of better readability, the generic masculine is used and the simultaneous use of the language forms male, female and diverse (m/f/d) is dispensed with. Unless otherwise indicated, the personal designations used in this patient information refer to all genders.

What is vestibular migraine?
When you think of 'migraine', you probably think of a throbbing headache that limits you. But if you suffer from repeated bouts of dizziness and other vestibular symptoms without headaches, you may have a vestibular migraine (VM). VM attacks can have a major impact on everyday life.
"Vestibular" refers to the movement sensors in the inner ear and the part of the brain that interprets the signals from the sensors. The sensors and the brain control your balance and perception of the space around you. If these sensors are not working properly or the brain misinterprets the signals, you may experience spinning vertigo, balance problems or dizzy spells.
A history of migraine headaches with or without aura (transient and reversible neurological disturbances) usually precedes vestibular migraine. Most people develop vestibular migraine after years or even decades of migraine headaches. However, vestibular migraine occurs in 3 out of 10 people without a history of migraine headaches.
Vestibular migraine is the most common cause of recurrent, spontaneous attacks of vertigo that last from minutes to several days. Spontaneous means that they occur suddenly for no apparent reason. Vestibular migraine is the third most common cause of vertigo after BPLS (benign paroxysmal positional vertigo) and persistent postural-perceptual dizziness (PPPD). Although vestibular migraine is relatively common, it is still too rarely diagnosed and treated.
To define VM vertigo attacks, patients describe a sensation of movement when there is no movement or an altered sensation of movement during normal movement. Patients describe this in various ways, e.g. as a rocking or swaying sensation, a spinning sensation or the sensation that the floor is moving.
Around 1 in 100 people will develop a vestibular migraine during their lifetime. Vestibular migraines are most common in midlife, but can occur at any age. The average age of onset is 37 for women and 42 for men. Vestibular migraine affects about 10% of all people who suffer from migraine.
Women suffer from vestibular migraine 5 times more often than men. The episodes could be related to the menstrual cycle.
People with a history of benign paroxysmal vertigo in childhood have an increased risk of developing vestibular migraine without migraine headaches.
Many people with vestibular migraine experienced motion sickness while driving as a child and continue to suffer from motion sickness as adults.
Around half of people with vestibular migraine have comorbid (concurrent) mental disorders such as mood swings, anxiety and depression.
Vestibular migraine is often a chronic condition. One study showed that in almost 30% of people with vestibular migraine, the frequency of episodes increased over a 9-year observation period, although it decreased in almost 50%. In the same study, 90% of people with vestibular migraine still reported episodes after 9 years.
Vestibular migraine is the internationally recognized term for this disorder. Some also call it migraine-associated vertigo, migraine-related vertigo or, more rarely, migraine-related vestibulopathy.
Summary
- Repeated attacks of dizziness, usually without simultaneous headaches.
- Is the most common cause of recurrent, spontaneous dizzy spells.
- Vestibular symptoms include spinning dizziness, unsteady gait and dizziness triggered by head movements and visual stimuli.
- The severity and combination of symptoms usually vary from seizure to seizure.
- The seizures usually last several hours to days and can have a significant impact on daily life.
- Sometimes the symptoms are similar to other diseases, which makes diagnosis more difficult.
- Vestibular migraine is often unrecognized or misdiagnosed.
- As a rule, only a specialist who is familiar with vestibular migraine can make an accurate diagnosis.
- Treatment includes avoiding triggers, making lifestyle changes and taking medication to reduce seizures.
- Vestibular rehabilitation should be tried, but only when the seizures are well controlled.
What causes vestibular migraines?
Migraine is a neurovascular headache. This means that it can be triggered by a disorder of the nerves or blood vessels in the brain. All forms of migraine are caused by the same type of neurotransmitter dysregulation. Neurotransmission is the process by which the brain receives and responds to signals.
Researchers are not sure what causes vestibular migraine. Some studies suggest that an abnormal release of neurotransmitters in the brain could play an important role. Genetics could also play a role. Around 80% of people who suffer from migraines report a family history of the condition.
In some people, there appears to be a link between vestibular migraine and other peripheral vestibular disorders, such as benign paroxysmal positional vertigo (BPLS) and Meniere's disease. The relationship between these disorders and vestibular migraine is complicated and not yet fully understood.
Many experts now believe that Meniere's disease and vestibular migraine belong to the same spectrum. Doctors tend to diagnose vestibular migraine when a person first suffers from migraine and then later develops vertigo. Meniere's disease is more likely to be diagnosed when a person suffers from vertigo with hearing loss from the beginning and when these attacks tend to be "short and severe".
Some people may have a peripheral vestibular disorder and vestibular migraine at the same time.
Vestibular symptoms of vestibular migraine during an attack include:
- Spontaneous dizziness (occurring without an obvious cause), with either a false perception of one's own movement or the feeling that the surroundings are spinning. A person with vestibular migraine may have the sensation that the ground is moving. Swaying vertigo is also often described.
- Positional vertigo triggered by a change in head position. Patients describe a feeling of spinning. This sometimes resembles benign paroxysmal positional vertigo (BPLS). However, VM vertigo usually occurs with any movement of the head, not just a specific change in head position. The situation is further complicated by the fact that patients with migraine are more likely to develop BPPV than those without migraine. If the movement-induced dizziness disappears on its own after a few days and cannot be resolved with relief maneuvers, it is most likely vestibular migraine.
- Visually induced dizziness triggered by a complex or large moving visual stimulus.
- Headache-induced dizziness that occurs with every movement of the head.
- Nausea that is triggered or worsened by any movement of the head.
- The feeling of disturbed spatial orientation. Many patients describe having the feeling that the world is askew, that they are separated from their body or that the ground is falling away beneath them.
- Gait instability and balance disorders
- Numbness or tingling
- Excessive susceptibility to motion sickness
- Difficulty concentrating, some patients also describe this as a "absorbent cotton feeling in the head"
- Speech disorders
- Temporary fluctuating hearing loss
- Feeling of fullness in the ear
- Tinnitus
- Sensitivity to light (photophobia), sounds (phonophobia) and/or odors (osmophobia)
- Extreme physical tiredness or weakness (prostration)
- Neck pain
- Visual disturbances, including flashes of light, blind spots, double or blurred vision (for some people, these are the precursors to a VM attack)
The above symptoms vary from person to person and from seizure to seizure. The symptoms also vary in severity. Only one or several symptoms may occur during a seizure.
VM dizziness can occur before, during or after the headache. There does not seem to be a consistent pattern. It varies from person to person and from attack to attack, even in the same person. It would be unusual to have a headache and dizziness at the same time during an attack. And in almost 30% of VM attacks, there is no headache at all.
The duration of the seizures varies greatly:
- 30% have seizures that last only minutes.
- 30% have attacks that last for hours.
- 30% have seizures lasting several days. For some sufferers, it can take up to a month to fully recover from a seizure. However, the actual seizure rarely lasts longer than 72 hours.
- 10% have seizures that last 10 seconds or less. They usually occur repeatedly during head movements, visual stimuli or after changes in head position. The length of the episodes is defined as the total period of time during which the short seizures recur. These transient seizures can be very distressing, especially for patients with anxiety.
Clinical experience has shown that vestibular migraine can also be chronic. Some patients report that they feel dizzy most days of the month. However, there is little scientific data on chronic VM.
Diagnosis of vestibular migraine
There is no test or imaging procedure that is "positive for vestibular migraine". Tests can only help to rule out other vestibular disorders. The diagnosis is based on the patient's medical history and the diagnostic criteria.
After an initial visit to your GP, you will probably be referred to a neurologist who specializes in migraine or vertigo. These specialized doctors will take a thorough medical history, perform a neurological examination and various tests to assess the function of your vestibular system.
Many of the symptoms of vestibular migraine are similar to the symptoms of other inner ear disorders such as Meniere's disease, benign paroxysmal positional vertigo (BPLS) and vestibular paroxysmia. Other disorders such as transient ischemic stroke (TIA), stroke with vertebrobasilar insufficiency (VBI) and episodic ataxia type 2 (EA2) can have similar symptoms to vestibular migraine. The similarity of symptoms can further complicate the diagnosis.
Before you receive a definitive diagnosis, diagnostic tests may be carried out to rule out other diseases. Examinations with special glasses can be helpful. This can differentiate between positional vertigo and positional nystagmus (involuntary, rapid eye movements), which occurs with vestibular migraine.
The currently recognized diagnostic criteria of the International Headache Society and the Barany Society (International Society of Neuro-otology) for vestibular migraine are:
- At least 5 episodes of vestibular disturbances of moderate or severe intensity lasting 5 minutes to 72 hours. Moderate means that the symptoms interfere with daily activities but are still possible. Severe symptoms mean that daily activities are impossible.
- A current or previous history of migraine with or without aura.
- At least half of the episodes are associated with at least one of the following 3 migraine characteristics:
- Headache with at least 2 of the following 4 characteristics:
- unilateral (one-sided) localization
- pulsating character
- moderate or severe pain intensity
- Reinforcement through routine physical activity
- Photophobia (sensitivity to light) and phonophobia (sensitivity to sound)
- Visual aura (flashes of light or blind spots in your field of vision)
- Headache with at least 2 of the following 4 characteristics:
- not better explained by another ICHD-3 diagnosis or another vestibular disorder.
Other symptoms that are often part of VM seizures are not included in the diagnostic criteria because they also occur in various other vestibular disorders.
The biggest problem in the treatment of vestibular migraine is the lack of diagnosis. It is estimated that many people with vestibular migraine go unrecognized or are misdiagnosed. Physician and patient bias can be problematic. For some patients, it is difficult to understand and accept that a migraine can occur without a headache.
Some doctors do not know how to recognize these unusual, atypical forms of migraine. The key to correctly diagnosing vestibular migraine is to recognize a link between vestibular symptoms and migraine and to be aware of the many different manifestations of this condition.
It is important that patients remain persistent. Do not accept the simple diagnosis of "unexplained dizziness".
Treatment of vestibular migraine
The treatment options for vestibular migraine are limited. The main aim of current treatment is to reduce the frequency of attacks. Strategies include:
- Reduction of triggers
- Lifestyle change
- Preventive medication
- Treatment of comorbidities (i.e. the presence of other chronic diseases)
- Vestibular rehabilitation therapy
- "Emergency" medication
Therapy option

Avoiding triggers
It can be helpful to keep a VM diary for 6 weeks. There are a number of migraine tracker apps that can be helpful. A diary can help with diagnosis and identifying triggers so you can avoid them. Some of the things that trigger other types of migraines can also trigger vestibular migraines. Make a note:
- when you go to bed and get up
- your activities during the day
- everything you eat and drink, and at what time
Sticking to a regular routine and changing your diet has been shown to help most patients. The triggers for vestibular migraines vary from person to person. Triggers can include:
- Stress and anxiety
Migraine in general is closely linked to stress and anxiety. Stress is probably the biggest trigger that most patients with vestibular migraine experience.
- Movement
- Traveling is a known VM trigger. Motion sickness, which is triggered by long car/train journeys, boats and airplanes, for example, triggers a VM attack in many people.
- Head movements, especially the rapid turning of the head, are also a common trigger.
- Many people report that intense visual stimuli, such as looking at large areas with complex patterns or movements, trigger a seizure (visually induced vertigo).
- Environmental factors
- In 9 out of 10 people with vestibular migraine, painful sensitivity to light (photophobia) can also occur. Bright light is a trigger for at least half of those affected. Flickering neon lights and glare can also be disturbing.
- Many people report that intense visual stimuli, such as high-contrast stripes or regular geometric patterns, can trigger a seizure.
- Perfume and other strong odors, such as paint thinner or chemicals in cleaning products, are triggers for some people.
- In some people, attacks are triggered by loud noises.
- Food and drink
Identify foods that trigger your VM attacks. It's probably not a question of giving up just one particular food, such as chocolate. There is usually more than one trigger or overlapping triggers. The most common triggers include sodium, tyramine, nitrates/nitrites, dairy products, caffeine, alcohol, gluten, carbohydrates, aspartame and monosodium glutamate. Not all sufferers' attacks are triggered by food. - Poor sleep
- Lack of sleep is one of the most common triggers for acute VM attacks. Too much sleep is also often cited as a trigger. Jet lag and changes in the working day can be triggers for some people.
- Almost all chronic VM patients - those who have daily pain or dizziness - suffer from insomnia. It is important that this is treated as it is associated with an increased risk of anxiety and depression. Your GP can prescribe medication to regulate your mood and improve your sleep.
- It is important to understand that depression does not cause dizziness. However, living with chronic dizziness can lead to depression.
- Hunger or dehydration
Research suggests that skipping meals and inadequate fluid intake are often associated with the onset of migraine. - Weather changes or changes in air pressure
Although research findings are limited, weather changes trigger migraines in some people. Thunderstorms with lightning are probably the most important weather-related trigger.
- Hormonal changes
These include menstruation, the menopause and puberty. Oral contraceptives ("the pill") can exacerbate symptoms. Pregnancy provides relief for some women, while for others the symptoms worsen during pregnancy. - Smoking
Smoking does not cause VM seizures in people who do not otherwise suffer from this disease. However, smoking can increase the frequency or intensity of seizures. - Excessive use of painkillers
50 - 80 % of people with vestibular migraine take excessive analgesics (painkillers). Headaches associated with VM respond extremely well to anti-inflammatory drugs such as ibuprofen or paracetamol. However, frequent use of these medications (about three times a week) can lead to rebound headaches. These can occur daily or with greater frequency. Patients with concomitant conditions, such as back or neck pain, may need to take painkillers to remain functional. Taking these medications may also contribute to triggering or worsening vestibular migraines. - Intensive exercise
A study has shown that 38% of migraine patients have had migraine attacks triggered by exercise.
Therapy option

Lifestyle changes
As well as avoiding triggers, lifestyle changes and keeping to a regular routine can also help to reduce the frequency and severity of VM attacks. The following steps can help:
- Balanced diet
Nutritionists are of the opinion that it is impossible to determine the one best diet. It is important to eat a nutrient-rich and protein-rich diet, drink enough fluids and pay attention to your carbohydrate intake. - Good sleep hygiene
VM attacks can be avoided through routine. People who always go to bed and get up at the same time can trigger a VM attack by sleeping in or getting up too early, for example. - Reducing stress and anxiety
Patients with vestibular migraine can benefit from exercises that calm their nervous system and reduce the intensity of their symptoms. Cognitive behavioral therapy (CBT) has been shown to be effective in reducing migraine frequency. People with vestibular migraines often suffer from anxiety. This can sometimes lead to depression. - Regular sport
Regular and daily physical activity can also be helpful. However, you should not exercise during the acute phase of an attack, as this can make your symptoms worse. General activity promotes recovery and overall health. Helpful strategies for avoiding a VM attack during exercise include:- Replace high-intensity activities with low-intensity activities
- Consume additional electrolytes
- Slow warm-up
- Don't let your heart rate rise above a certain number of beats per minute (this varies from person to person)
- Taking magnesium citrate
The additional intake of magnesium citrate and vitamin B2 (riboflavin) has been shown to reduce VM seizures in around 10% of people. Supplementation must be tried for 6 weeks before its effectiveness can be assessed. - Avoid dehydration
Adequate hydration could prevent a VM attack. Drink water before you feel thirsty and before you are physically active. - Neck and back pain
The way your neck and back move plays a big part in vestibular migraines. For example, if you suffer from chronic neck and back pain, sitting for long periods of time can trigger pain in the back of your head - or in some cases, the front of your head. Even a slight change in desk or chair height can make a huge difference. If you work, ask for an ergonomic assessment of your workstation. If you work from home, consider having your home office ergonomically assessed. Daily stretching and cooling your neck can also help. Try to change your position regularly and avoid long static postures.
Therapy option

Preventive medication
If you struggle with symptoms for more than 10 days a month, your doctor may consider other preventative measures. The goal of a preventative medication strategy is to reduce VM attacks by at least 50%. This can especially help people with triggers that are difficult to avoid, such as changes in hormone levels.
Several medications that were actually developed for other conditions can help prevent seizures. These include:
- Selective serotonin reuptake inhibitors (SSRIs) or serotonin or serotonin/norepinephrine reuptake inhibitors (SNRAs)
- Anticonvulsants (medication against seizures)
- Botulinum toxin injections are the first choice for migraine treatment. They have no side effects and have proven themselves in clinical studies.
- Beta blockers such as propranolol. They act on the vascular part of the migraine and can help to prevent the heart rate from increasing during physical exertion.
- Calcium channel blockers
- Monoclonal antibodies against the calcitonin gene are a newer biological therapy for chronic migraine.
The above medications can be very effective, especially for vestibular migraines with headaches. They can also work for people who only suffer from an aura. A person taking preventative medication usually needs to take it daily. Regardless of the symptoms, however, the doctor's advice should be followed. If there is no other effective treatment, preventive medication should at least be tried.
Therapy option

Vestibular rehabilitation therapy
If you have started with the above-mentioned therapy measures, vestibular rehabilitation therapy can also help. This can strengthen your balance and reduce your persistent symptoms. Vestibular rehabilitation is an exercise therapy.
It is very important that you have the vestibular migraine under control before you start vestibular rehabilitation. Your dizziness and balance will not improve, despite your best efforts, if the underlying problem of vestibular migraine has not been adequately treated. Vestibular rehabilitation should be considered for all VM patients. A certified IVRT® Dizziness and Vestibular Therapist can document your progress and guide you through treatment.
It is important that you are patient and do your exercises every day. However, don't try to overdo it. If you continue vestibular rehabilitation despite worsening VM symptoms, your vestibular migraines may worsen, increasing the frequency and severity of your symptoms. If vestibular rehabilitation therapy worsens your migraine attacks, be sure to talk to your therapist.
Therapy option

Emergency medication
If the above treatments do not work, some medications can help to "save" you. They cannot prevent VM attacks from occurring, but once an attack starts, they can restore the serotonin balance in the brain and thus treat the attack. Emergency medications include:
- Non-steroidal anti-inflammatory drugs: Caution is advised with these drugs, as the brain reacts very sensitively to them.
- Metoclopramide
- Triptans: Studies show that these drugs have little effect on dizziness and are more effective in treating headaches.
- Antiemetics (medication to prevent vomiting) such as dimenhydrinate and benzodiazepines
Living with vestibular migraine
Vestibular migraine is a chronic condition that can have a significant impact on daily life. It can leave you feeling too weak to perform basic activities such as sleeping, walking or driving. Frequent attacks of VM can have a negative impact on your career, education and relationships with family and friends.
Tips for living with vestibular migraine:
- At the first signs of an attack, you should go into a dark room, drink a glass of water and lie down. Essential oils such as lavender or peppermint under your nose could also help.
- Keep a health diary and look out for patterns. For example, which foods trigger an attack? Is there a particular sign that an attack is imminent?
- Consider using a transdermal scopolamine patch to prevent motion sickness on long car trips, long haul flights or cruises. One patch lasts for 3 days and can be used safely for up to 6 consecutive days. Remove the patch immediately at the end of your trip. Alternatively, you can use dimenhydrinate or another medication recommended by your doctor as a pre-treatment.
- If you are persistently photophobic (sensitive to light), you should not wear sunglasses indoors. Wearing sunglasses will exacerbate your sensitivity to light. Consider wearing lenses with the FL-41 optical tint instead.
- If you suffer from persistent phonophobia (sensitivity to noise), you should not use earplugs all the time. Most earplugs exacerbate noise intolerance. Only use them for activities where the noise level exceeds the safety limits, e.g. mowing the lawn. If you are too sensitive to noise, you should visit an ENT practice that offers tinnitus retraining therapy or "pink noise" therapy.
- Many people don't know much about vestibular migraines, so you may need to educate your family and friends about them. Let them know if they can take certain steps to support you.
- If you understand the condition, you can deal with it better. It can be helpful to learn as much as you can about vestibular migraine.
- For some people, it helps to talk to others who suffer from the same illness. Support groups, whether online or in person, can help you to share information and tips and give you the feeling that you are not alone.
Continuous treatment of vestibular migraine can significantly improve the quality of life and help both in the treatment and prevention of attacks.
What happens next?
What you can expect in the future.
The current diagnostic criteria established by the International Headache Society (IHS) and the Barany Society are likely to evolve. A future revision could include an overlap syndrome of vestibular migraine and Meniere's disease. Further studies on the different forms of migraine, including chronic and persistent forms, are needed.
A small, preliminary study suggests that non-invasive vagus nerve stimulation with a wearable device placed on the neck may provide rapid relief of acute vestibular migraine. However, further research is needed before vagus nerve stimulation can be recommended as an effective treatment for vestibular migraine.
There is still a long way to go to adequately help people with vestibular migraine, but awareness of this disorder is steadily increasing. In the last 5 to 10 years, the level of knowledge has increased significantly and the prospects for better treatment options are promising.
In order to keep this patient information as short as possible, we have not included a detailed list of references. However, this can be requested at any time at info@ivrt.de.