Vestibular Migraine: Symptoms, Diagnosis and Treatment

What is vestibular migraine?

Vestibular migraine (formerly “migrainous vertigo” or “migraine-associated vertigo”) is a neurological condition in which the same brain mechanisms that produce migraine disturb balance. It affects about 1–3% of the population and is more common in women, typically starting in the 30s or 40s, often in people with a history of migraine or motion sickness. It can occur at any age, including childhood.

Headache is not required during every episode: some people have dizziness alone, which is why it is frequently missed.

Symptoms

Vertigo: a spinning sensation, sometimes triggered by head movement.
Dizziness or imbalance: feeling unsteady, floating, or “off”.
Motion sensitivity: worse in cars, buses, supermarkets, scrolling on screens or busy visual environments.
Headache, often throbbing and one-sided, in some but not all episodes.
Sensitivity to light (photophobia) and sound (phonophobia), and visual aura.
Nausea and vomiting.
Ear symptoms: fullness, pressure or mild tinnitus, usually without significant hearing loss.
Anxiety and brain fog during and between episodes.

How it is diagnosed

The Bárány Society and the International Headache Society consensus criteria require at least five episodes of vestibular symptoms of moderate or severe intensity lasting between 5 minutes and 72 hours, a current or past history of migraine, and migraine features (headache with specific characteristics, light and sound sensitivity or visual aura) during at least half of the episodes, with no better explanation by another diagnosis. “Probable vestibular migraine” is used when not all criteria are met.

Your doctor may order a hearing test and balance tests, and sometimes an MRI, mainly to rule out other conditions. Normal tests support the diagnosis.

Vestibular migraine versus other dizziness

BPPV: short spinning episodes (under a minute) triggered by specific head positions, treated with repositioning manoeuvres.
Ménière’s disease: episodes of 20 minutes to 12 hours with fluctuating low-frequency hearing loss, tinnitus and ear fullness.
Vestibular neuritis: a single, severe episode of vertigo lasting days, with no headache.
Stroke or TIA: sudden vertigo with other neurological signs.
Anxiety and persistent postural-perceptual dizziness (PPPD): chronic unsteadiness worse in busy environments; sometimes follows vestibular migraine.
See vertigo for a general overview.

Common triggers

Stress and anxiety, or relaxation after stress (“let-down”).
Poor or irregular sleep.
Skipping meals, dehydration, caffeine changes and alcohol (red wine in particular).
Hormonal changes, such as around menstruation.
Strong smells, bright or flickering lights, screens and busy visual patterns.
Weather and barometric changes, and travel.
Certain foods, although food triggers are less consistent than often believed.
Keeping a symptom and trigger diary for 4–6 weeks is very helpful.

Treatment

There is no one-size-fits-all treatment, and the evidence is still limited compared with typical migraine. Approaches include:

Lifestyle: regular sleep, regular meals, hydration, moderate exercise, limiting caffeine and alcohol, stress management.
Acute treatment during attacks: anti-nausea medication, vestibular suppressants for a day or two only, and migraine-specific treatments such as triptans if headache is present, according to your doctor.
Preventive medicines when attacks are frequent or disabling: options include beta-blockers, certain anticonvulsants, tricyclics, venlafaxine, flunarizine (not available in all countries), CGRP-targeted treatments and others, chosen by your doctor or neurologist.
Vestibular rehabilitation with a physiotherapist for persistent imbalance and motion sensitivity.
CBT and relaxation to reduce anxiety and avoidance.

Vestibular rehabilitation

Vestibular physical therapy uses graded exercises (gaze stabilisation, balance training, habituation to movement and visual environments) to help the brain compensate. It is helpful when dizziness persists between attacks or you avoid certain environments out of fear. It usually starts when the attacks are better controlled and is supervised by a trained physiotherapist.

When to see a doctor

Recurrent episodes of dizziness or vertigo, especially with headache or light sensitivity.
Dizziness that interferes with work, driving or daily life.
Hearing loss, ringing or ear fullness that fluctuates.
New headache patterns or any neurological symptoms (emergency).
Dizziness after a head injury or in someone with vascular risk factors: urgent assessment.

Three common situations

Woman in her 30s with migraine, repeated dizzy spells before her period: consistent with vestibular migraine; keep a diary and talk to your doctor about treatment.

Dizziness for hours without headache, worse in supermarkets and when scrolling: visual motion sensitivity is typical; consider vestibular rehabilitation.

Spinning for seconds when turning in bed: more typical of BPPV; ask for positional testing.

Key points to remember

Vestibular migraine is common, treatable and frequently underdiagnosed. A careful history, avoiding triggers, a regular routine, targeted medication and vestibular rehabilitation can help most people. Emergencies with neurological signs must be ruled out first.

This guide is for general information and does not replace an assessment by your own doctor or ENT specialist.

Questions about vestibular migraine

These answers are general information and do not replace an examination or individual medical advice.

Can you have vestibular migraine without a headache?

Yes. Many episodes consist of dizziness or vertigo alone, though other migraine features are usually present in at least half of the attacks.

How long does a vestibular migraine attack last?

From five minutes to 72 hours, with large individual variation.

How is it different from BPPV?

BPPV causes brief spinning (under a minute) triggered by head position and is treated with repositioning manoeuvres. Vestibular migraine lasts longer and has migraine features.

What triggers vestibular migraine?

Stress, poor sleep, skipped meals, hormonal changes, alcohol, bright or flickering lights and weather changes are common triggers.

Is there a cure?

There is no cure, but most people reduce attacks with lifestyle changes, medication and rehabilitation.

Which specialist treats it?

ENT doctors, neurologists and specialist balance clinics, often working together.

Sources

This guide is for general information and does not replace medical advice. How a problem is diagnosed and treated depends on your examination and medical history. If you think you have an emergency, contact your local emergency services.