Vol 54, No 2 (2020)
Invited Review Article
Published online: 2020-04-09

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Vestibular migraine — an underdiagnosed cause of vertigo. Diagnosis and treatment

Magdalena Nowaczewska12
Pubmed: 32285435
Neurol Neurochir Pol 2020;54(2):106-115.


Introduction. Migraine and vertigo are two common conditions. The main disorder connecting both these entities is vestibular migraine (VM).

State of the art. VM may affect 1–3% of the general population. It is a disabling disease of recurrent attacks of vestibular symptoms accompanied by migraine features which occur in patients with a current or previous history of migraine. The episodes can last minutes, hours or even days, and may occur without any concurrent headache, which can prompt misdiagnosis. VM often begins several years after a typical migraine, and the delay between onset of headache and vertigo may be long. The diagnosis is based on the patient’s clinical history and can be challenging due to the lack of an established confirmatory diagnostic test or biomarkers. The mechanism of vestibular migraine remains unclear and is still under investigation, but it seems to be an interaction between trigeminal and vestibular systems. Due to the lack of specific trials, treatment recommendations are based on migraine guidelines. Several drugs seem to be effective, although there have been few randomised controlled trials in this area. Regardless of the published strict and detailed diagnostic criteria, this condition remains little known, and as a consequence is underdiagnosed and undertreated.

Clinical implications. Efforts should be made to educate medical communities and patients about this disease and to encourage neurologists and ENT specialists to cooperate. Every patient with vertigo of unknown origin should be directly asked about a past or present history of migraine, or migraine symptoms experienced during their vertigo episodes.

Future directions. There is a growing need for studies regarding the pathophysiology of VM as well as randomised trials to establish clear treatment recommendations and to improve management of this surprisingly common disorder.

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  1. Neuhauser HK, Radtke A, von Brevern M, et al. Migrainous vertigo: prevalence and impact on quality of life. Neurology. 2006; 67(6): 1028–1033.
  2. Vuković V, Plavec D, Galinović I, et al. Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine. Headache. 2007; 47(10): 1427–1435.
  3. Calhoun AH, Ford S, Pruitt AP, et al. The point prevalence of dizziness or vertigo in migraine--and factors that influence presentation. Headache. 2011; 51(9): 1388–1392.
  4. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018; 38(1): 1–211.
  5. Lempert T, Brevern Mv. Vestibular Migraine. Neurol Clin. 2019; 37(4): 695–706.
  6. Geser R, Straumann D. Referral and final diagnoses of patients assessed in an academic vertigo center. Front Neurol. 2012; 3: 169.
  7. Formeister EJ, Rizk HG, Kohn MA, et al. The Epidemiology of Vestibular Migraine: A Population-based Survey Study. Otol Neurotol. 2018; 39(8): 1037–1044.
  8. Teggi R, Colombo B, Albera R, et al. Clinical Features, Familial History, and Migraine Precursors in Patients With Definite Vestibular Migraine: The VM-Phenotypes Projects. Headache. 2018; 58(4): 534–544.
  9. Cho SJ, Kim BK, Kim BS, et al. Vestibular migraine in multicenter neurology clinics according to the appendix criteria in the third beta edition of the International Classification of Headache Disorders. Cephalalgia. 2016; 36(5): 454–462.
  10. Yollu U, Uluduz DU, Yilmaz M, et al. Vestibular migraine screening in a migraine-diagnosed patient population, and assessment of vestibulocochlear function. Clin Otolaryngol. 2017; 42(2): 225–233.
  11. Cha YH, Lee H, Santell LS, et al. Association of benign recurrent vertigo and migraine in 208 patients. Cephalalgia. 2009; 29(5): 550–555.
  12. Martinez E, Ruiz-Pinero M, de Lera M, et al. [Clinical characteristics of vestibular migraine: considerations in a series of 41 patients]. Rev Neurol. 2017; 64(1): 1–6.
  13. Neuhauser H, Leopold M, von Brevern M, et al. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology. 2001; 56(4): 436–441.
  14. Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016; 263 Suppl 1: S82–S89.
  15. Vuralli D, Yildirim F, Akcali DT, et al. Visual and Postural Motion-Evoked Dizziness Symptoms Are Predominant in Vestibular Migraine Patients. Pain Med. 2018; 19(1): 178–183.
  16. Beh SC, Masrour S, Smith SV, et al. The Spectrum of Vestibular Migraine: Clinical Features, Triggers, and Examination Findings. Headache. 2019; 59(5): 727–740.
  17. Power L, Shute W, McOwan B, et al. Clinical characteristics and treatment choice in vestibular migraine. J Clin Neurosci. 2018; 52: 50–53.
  18. Teggi R, Colombo B, Albera R, et al. Clinical Features of Headache in Patients With Diagnosis of Definite Vestibular Migraine: The VM-Phenotypes Projects. Front Neurol. 2018; 9.
  19. Zhang Y, Kong Q, Chen J, et al. International Classification of Headache Disorders 3rd edition beta-based field testing of vestibular migraine in China: Demographic, clinical characteristics, audiometric findings and diagnosis statues. Cephalalgia. 2016; 36(3): 240–248.
  20. Lempert T, Neuhauser H. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol. 2009; 256(3): 333–338.
  21. Thakar A, Anjaneyulu C, Deka RC. Vertigo syndromes and mechanisms in migraine. J Laryngol Otol. 2001; 115(10): 782–787.
  22. Baloh RW. Vestibular Migraine I: Mechanisms, Diagnosis, and Clinical Features. Semin Neurol. 2020; 40(1): 76–82.
  23. Colombo B, Teggi R. NIVE Project. Vestibular migraine: who is the patient? Neurol Sci. 2017; 38(Suppl 1): 107–110.
  24. Chang TP, Hsu YC. Vestibular migraine has higher correlation with carsickness than non-vestibular migraine and Meniere's disease. Acta Neurol Taiwan. 2014; 23(1): 4–10.
  25. Beh SC. Vestibular Migraine: How to Sort it Out and What to Do About it. J Neuroophthalmol. 2019; 39(2): 208–219.
  26. Popkirov S, Staab JP, Stone J. Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018; 18(1): 5–13.
  27. Millen SJ, Schnurr CM, Schnurr BB. Vestibular migraine: perspectives of otology versus neurology. Otol Neurotol. 2011; 32(2): 330–337.
  28. Furman JM, Marcus DA, Balaban CD. Vestibular migraine: clinical aspects and pathophysiology. Lancet Neurol. 2013; 12(7): 706–715.
  29. Espinosa-Sanchez JM, Lopez-Escamez JA. New insights into pathophysiology of vestibular migraine. Front Neurol. 2015; 6: 12.
  30. Kreczmański P, Wolak T, Lewandowska M, et al. Altered functional brain imaging in migraine patients: BOLD preliminary study in migraine with and without aura. Neurol Neurochir Pol. 2019; 53(4): 304–310.
  31. Balaban CD, Black RD, Silberstein SD. Vestibular Neuroscience for the Headache Specialist. Headache. 2019; 59(7): 1109–1127.
  32. Liu YF, Xu H. The Intimate Relationship between Vestibular Migraine and Meniere Disease: A Review of Pathogenesis and Presentation. Behav Neurol. 2016; 2016: 3182735.
  33. King S, Priesol AJ, Davidi SE, et al. Self-motion perception is sensitized in vestibular migraine: pathophysiologic and clinical implications. Sci Rep. 2019; 9(1): 14323.
  34. Ashish G, Augustine AM, Tyagi AK, et al. Subjective Visual Vertical and Horizontal in Vestibular Migraine. J Int Adv Otol. 2017; 13(2): 254–258.
  35. Li P, Gu H, Xu J, et al. Purkinje cells of vestibulocerebellum play an important role in acute vestibular migraine. J Integr Neurosci. 2019; 18(4): 409–414.
  36. Russo A, Marcelli V, Esposito F, et al. Abnormal thalamic function in patients with vestibular migraine. Neurology. 2014; 82(23): 2120–2126.
  37. Messina R, Rocca MA, Colombo B, et al. Structural brain abnormalities in patients with vestibular migraine. J Neurol. 2017; 264(2): 295–303.
  38. Shin JH, Kim YuK, Kim HJ, et al. Altered brain metabolism in vestibular migraine: comparison of interictal and ictal findings. Cephalalgia. 2014; 34(1): 58–67.
  39. Jeong SH, Oh SY, Kim HJ, et al. Vestibular dysfunction in migraine: effects of associated vertigo and motion sickness. J Neurol. 2010; 257(6): 905–912.
  40. Wu X, Qiu F, Wang Z, et al. Correlation of 5-HTR6 gene polymorphism with vestibular migraine. J Clin Lab Anal. 2020; 34(2): e23042.
  41. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012; 22(4): 167–172.
  42. Abouzari M, Goshtasbi K, Moshtaghi O, et al. Association Between Vestibular Migraine and Migraine Headache: Yet to Explore. Otol Neurotol. 2020; 41(3): 392–396.
  43. Radtke A, von Brevern M, Neuhauser H, et al. Vestibular migraine: long-term follow-up of clinical symptoms and vestibulo-cochlear findings. Neurology. 2012; 79(15): 1607–1614.
  44. Balci B, Şenyuva N, Akdal G. Definition of Balance and Cognition Related to Disability Levels in Vestibular Migraine Patients. Noro Psikiyatr Ars. 2018; 55(1): 9–14.
  45. Beh SC, Masrour S, Smith SV, et al. Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine. Neurol Clin Pract. 2018; 8(5): 389–396.
  46. Kutay Ö, Akdal G, Keskinoğlu P, et al. Vestibular migraine patients are more anxious than migraine patients without vestibular symptoms. J Neurol. 2017; 264(Suppl 1): 37–41.
  47. Chądzyński P, Kacprzak A, Domitrz W, et al. Migraine headache facilitators in a population of Polish women and their association with migraine occurrence - preliminary results. Neurol Neurochir Pol. 2019; 53(5): 377–383.
  48. Neugebauer H, Adrion C, Glaser M, et al. Long-term changes of central ocular motor signs in patients with vestibular migraine. Eur Neurol. 2013; 69(2): 102–107.
  49. von Brevern M, Zeise D, Neuhauser H, et al. Acute migrainous vertigo: clinical and oculographic findings. Brain. 2005; 128(Pt 2): 365–374.
  50. El-Badry MM, Samy H, Kabel AM, et al. Clinical criteria of positional vertical nystagmus in vestibular migraine. Acta Otolaryngol. 2017; 137(7): 720–722.
  51. Dieterich M, Brandt T. Episodic vertigo related to migraine (90 cases): vestibular migraine? J Neurol. 1999; 246(10): 883–892.
  52. Radtke A, Lempert T, Gresty MA, et al. Migraine and Ménière's disease: is there a link? Neurology. 2002; 59(11): 1700–1704.
  53. Pyykkö I, Pyykkö N, Manchaiah V, et al. Association between Ménière's disease and vestibular migraine. Auris Nasus Larynx. 2019; 46(5): 724–733.
  54. Shin CHo, Kim Y, Yoo MH, et al. Management of Ménière's Disease: How Does the Coexistence of Vestibular Migraine Affect Outcomes? Otol Neurotol. 2019; 40(5): 666–673.
  55. Wang Y, Diao T, Zhao Y, et al. The clinical characteristics and audiogram in 103 Meniere's disease patients with and without vestibular migraine. Clin Otolaryngol. 2018; 43(1): 343–347.
  56. Murofushi T, Tsubota M, Kitao K, et al. Simultaneous Presentation of Definite Vestibular Migraine and Definite Ménière's Disease: Overlapping Syndrome of Two Diseases. Front Neurol. 2018; 9: 749.
  57. Lopez-Escamez JA, Dlugaiczyk J, Jacobs J, et al. Accompanying Symptoms Overlap during Attacks in Menière's Disease and Vestibular Migraine. Front Neurol. 2014; 5: 265.
  58. Tabet P, Saliba I. Meniere's Disease and Vestibular Migraine: Updates and Review of the Literature. J Clin Med Res. 2017; 9(9): 733–744.
  59. Gürkov R, Kantner C, Strupp M, et al. Endolymphatic hydrops in patients with vestibular migraine and auditory symptoms. Eur Arch Otorhinolaryngol. 2014; 271(10): 2661–2667.
  60. Zuniga MG, Janky KL, Schubert MC, et al. Can vestibular-evoked myogenic potentials help differentiate Ménière disease from vestibular migraine? Otolaryngol Head Neck Surg. 2012; 146(5): 788–796.
  61. Blödow A, Heinze M, Bloching MB, et al. Caloric stimulation and video-head impulse testing in Ménière's disease and vestibular migraine. Acta Otolaryngol. 2014; 134(12): 1239–1244.
  62. Cohen JM, Escasena CA. Headache and Dizziness: How to Differentiate Vestibular Migraine from Other Conditions. Curr Pain Headache Rep. 2015; 19(7): 31.
  63. Baier B, Stieber N, Dieterich M. Vestibular-evoked myogenic potentials in vestibular migraine. J Neurol. 2009; 256(9): 1447–1454.
  64. Bednarczuk NF, Bonsu A, Ortega MC, et al. Abnormal visuo-vestibular interactions in vestibular migraine: a cross sectional study. Brain. 2019; 142(3): 606–616.
  65. Boldingh MI, Ljøstad U, Mygland A, et al. Vestibular sensitivity in vestibular migraine: VEMPs and motion sickness susceptibility. Cephalalgia. 2011; 31(11): 1211–1219.
  66. Cesaroni S, Silva AM, Ganança MM, et al. Postural control at posturography with virtual reality in the intercritical period of vestibular migraine. Braz J Otorhinolaryngol. 2019 [Epub ahead of print].
  67. Gorski LP, Silva AM, Cusin FS, et al. Body balance at static posturography in vestibular migraine. Braz J Otorhinolaryngol. 2019; 85(2): 183–192.
  68. Inoue A, Egami N, Fujimoto C, et al. Vestibular Evoked Myogenic Potentials in Vestibular Migraine: Do They Help Differentiating From Menière's Disease? Ann Otol Rhinol Laryngol. 2016; 125(11): 931–937.
  69. Kang WS, Lee SH, Yang CJ, et al. Vestibular Function Tests for Vestibular Migraine: Clinical Implication of Video Head Impulse and Caloric Tests. Front Neurol. 2016; 7: 166.
  70. Makowiec KF, Piker EG, Jacobson GP, et al. Ocular and Cervical Vestibular Evoked Myogenic Potentials in Patients With Vestibular Migraine. Otol Neurotol. 2018; 39(7): e561–e567.
  71. Sharon JD, Hullar TE. Motion sensitivity and caloric responsiveness in vestibular migraine and Meniere's disease. Laryngoscope. 2014; 124(4): 969–973.
  72. Boldingh MI, Ljøstad U, Mygland Å, et al. Comparison of interictal vestibular function in vestibular migraine vs migraine without vertigo. Headache. 2013; 53(7): 1123–1133.
  73. Morganti LO, Salmito MC, Duarte JA, et al. Vestibular migraine: clinical and epidemiological aspects. Braz J Otorhinolaryngol. 2016; 82(4): 397–402.
  74. Vitkovic J, Paine M, Rance G. Neuro-otological findings in patients with migraine- and nonmigraine-related dizziness. Audiol Neurootol. 2008; 13(2): 113–122.
  75. Salviz M, Yuce T, Acar H, et al. Diagnostic value of vestibular-evoked myogenic potentials in Ménière's disease and vestibular migraine. J Vestib Res. 2016; 25(5-6): 261–266.
  76. Lim YH, Kim JS, Lee HW, et al. Postural Instability Induced by Visual Motion Stimuli in Patients With Vestibular Migraine. Front Neurol. 2018; 9: 433.
  77. Wang S, Wang H, Zhao D, et al. Grey matter changes in patients with vestibular migraine. Clin Radiol. 2019; 74(11): 898.e1–898.e5.
  78. Obermann M, Wurthmann S, Steinberg BS, et al. Central vestibular system modulation in vestibular migraine. Cephalalgia. 2014; 34(13): 1053–1061.
  79. Çelik O, Tanyeri Toker G, Eskiizmir G, et al. The Effectiveness of Medical Prophylactic Treatment on Vestibular Migraine and Its Effect on the Quality Of Life. J Int Adv Otol. 2019 [Epub ahead of print].
  80. Domínguez-Durán E, Baños-López P, Martín-Castillo E, et al. Inter-rater agreement in the choice of prophylactic treatment for vestibular migraine and role of an assisted algorithm for this choice. Acta Otorrinolaringol Esp. 2019 [Epub ahead of print].
  81. Lauritsen CG, Marmura MJ. Current Treatment Options: Vestibular Migraine. Curr Treat Options Neurol. 2017; 19(11): 38.
  82. Salmito MC, Morganti LO, Nakao BH, et al. Vestibular migraine: comparative analysis between diagnostic criteria. Braz J Otorhinolaryngol. 2015; 81(5): 485–490.
  83. Domínguez-Durán E, Montilla-Ibáñez MA, Álvarez-Morujo de Sande MG, et al. Analysis of the effectiveness of the prophylaxis of vestibular migraine depending on the diagnostic category and the prescribed drug. Eur Arch Otorhinolaryngol. 2020; 277(4): 1013–1021.
  84. Byun YJ, Levy DA, Nguyen SA, et al. Treatment of Vestibular Migraine: A Systematic Review and Meta-analysis. Laryngoscope. 2020 [Epub ahead of print].
  85. Fotuhi M, Glaun B, Quan SY, et al. Vestibular migraine: a critical review of treatment trials. J Neurol. 2009; 256(5): 711–716.
  86. Alghadir AH, Anwer S. Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review. Front Neurol. 2018; 9: 440.
  87. Sugaya N, Arai M, Goto F. Is the Headache in Patients with Vestibular Migraine Attenuated by Vestibular Rehabilitation? Front Neurol. 2017; 8: 124.
  88. Beh SC. External trigeminal nerve stimulation: Potential rescue treatment for acute vestibular migraine. J Neurol Sci. 2020; 408: 116550.
  89. Beh SC, Friedman DI. Acute vestibular migraine treatment with noninvasive vagus nerve stimulation. Neurology. 2019; 93(18): e1715–e1719.
  90. Kong WJ, Scholtz AW, Kammen-Jolly K, et al. Ultrastructural evaluation of calcitonin gene-related peptide immunoreactivity in the human cochlea and vestibular endorgans. Eur J Neurosci. 2002; 15(3): 487–497.
  91. Xiaocheng W, Zhaohui S, Junhui X, et al. Expression of calcitonin gene-related peptide in efferent vestibular system and vestibular nucleus in rats with motion sickness. PLoS One. 2012; 7(10): e47308.
  92. Bayer O, Adrion C, Al Tawil A, et al. PROVEMIG investigators. Results and lessons learnt from a randomized controlled trial: prophylactic treatment of vestibular migraine with metoprolol (PROVEMIG). Trials. 2019; 20(1): 813.
  93. Kaya I, Eraslan S, Tarhan C, et al. Can verapamil be effective in controlling vertigo and headache attacks in vestibular migraine accompanied with Meniere's disease? A preliminary study. J Neurol. 2019; 266(Suppl 1): 62–64.
  94. Liu F, Ma T, Che X, et al. The Efficacy of Venlafaxine, Flunarizine, and Valproic Acid in the Prophylaxis of Vestibular Migraine. Front Neurol. 2017; 8: 524.
  95. Salmito M, Duarte J, Morganti L, et al. Prophylactic treatment of vestibular migraine. Braz J Otorhinolaryngol. 2017; 83(4): 404–410.
  96. Çelebisoy N, Gökçay F, Karahan C, et al. Acetazolamide in vestibular migraine prophylaxis: a retrospective study. Eur Arch Otorhinolaryngol. 2016; 273(10): 2947–2951.
  97. Salviz M, Yuce T, Acar H, et al. Propranolol and venlafaxine for vestibular migraine prophylaxis: A randomized controlled trial. Laryngoscope. 2016; 126(1): 169–174.
  98. Cassano D, Pizza V, Busillo V. P074. Almotriptan in the acute treatment of Vestibular migraine: a retrospective study. J Headache Pain. 2015; 16(Suppl 1): A114.
  99. Teggi R, Colombo B, Gatti O, et al. Fixed combination of cinnarizine and dimenhydrinate in the prophylactic therapy of vestibular migraine: an observational study. Neurol Sci. 2015; 36(10): 1869–1873.
  100. Taghdiri F, Togha M, Razeghi Jahromi S, et al. Cinnarizine for the prophylaxis of migraine associated vertigo: a retrospective study. Springerplus. 2014; 3: 231.
  101. Mikulec AA, Faraji F, Kinsella LJ. Evaluation of the efficacy of caffeine cessation, nortriptyline, and topiramate therapy in vestibular migraine and complex dizziness of unknown etiology. Am J Otolaryngol. 2012; 33(1): 121–127.
  102. Neuhauser H, Radtke A, von Brevern M, et al. Zolmitriptan for treatment of migrainous vertigo: a pilot randomized placebo-controlled trial. Neurology. 2003; 60(5): 882–883.

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