Vestibular Migraine

Migraine does not mean “headache”  

In fact, there are many types of migraine that involve no headache at all.  It just so happens that the most common two types of migraine in the population are the headache varieties; Common Migraine and Classical migraine.

Migraine is actually a condition of altered sensation and can happen at any age and in any part of the body.  For example, babies may present with migraine in the form of “cyclical vomiting”. Children present with “Abdominal Migraine” having tummy pains and diarrhoea, and adults can also have abdominal migraine, but we know it by a different name – Irritable Bowel Syndrome!  Migraine can also present as motion sickness, facial pain and joint pains without any headache at all.

Vestibular migraine is the internationally accepted term for a type of migraine that mainly presents with dizziness symptoms. The duration of attacks are very variable, being from seconds in some patients to days in others, but usually lasts minutes to hours. They mostly occur without headaches, although in around half of patients are followed by or occur with a headache or visual changes.

Vestibular migraine typically is associated with nausea, vomiting, sweating, flushing, diarrhoea and visual changes such as blurring, flashing lights and difficulty focussing. Patients also report difficulty concentrating, finding bright lights and loud sounds uncomfortable, and most commonly feel extreme tiredness and fatigue, needing to sleep.

Who is affected?

Vestibular migraine is the most common cause of recurrent spontaneous vertigo and the second most common vestibular disorder after benign paroxysmal positional vertigo. It affects about 10% of all migraineurs. Vestibular migraine may start at any age and has a female preponderance of about 3:1. Familial occurrence is common, pointing to a genetic origin of the disorder.

There is a strong association with Ménière’s disease with approximately half of people with Ménière’s disease experiencing at least one migraine symptom during a Ménière’s attack.  The two conditions can coincide in 40% of patients with Ménière’s disease. Therefore Vestibular migraine must always be considered in any patient with Ménière’s disease, whose symptoms recur unexpectedly, and before any destructive Ménière’s treatment is contemplated.

Benign paroxysmal vertigo of childhood designates a variant of vestibular migraine that starts at pre school age with brief attacks of isolated vertigo which tend to be replaced by typical headache migraine after a few years.

How is vestibular migraine diagnosed?

Vestibular migraine is diagnosed on the basis of patient’s history. The commonest (benign) neurological condition to mimic BPPV is a form of migraine. Attacks can last seconds, minutes, hours or even last days in some patients and are often not associated with headache. Often the presence of concurrent symptoms not expected in Ménière’s disease such as visual symptoms during attacks is the key to the diagnosis. This may include blurred vision or sensitivity to light.  Patients also often complain of extreme fatigue immediately following an attack.

Vestibular migraine can cause attacks which are not unlike those of Ménière’s and which are often misdiagnosed as such without expertise!

Vestibular migraine is also known as migrainous vertigo, migraine-associated dizziness, migraine-related vestibulopathy, and recurrent vertigo, however the internationally accepted term (of the Barany Society) is vestibular migraine.

How is it treated?

Migraine in general has been shown to be closely related to anxiety and depression and the most common cause is stress!  Most patients have one or more specific triggers and treatment therefore centres on identifying and managing these triggers in individual patients.

The top 5 most common triggers for vestibular migraine are:

- Stress and anxiety.

- Poor sleep – both too little, and too much!

- Hunger and dehydration – missing meals and not taking enough water

-  Dietary triggers – many common foods, especially caffeine

- Hormonal changes – ie menstruation, menopause and in teenagers.

Other external triggers can include certain forms of lighting and ventilation, weather changes, smoking and strong odours.

Initial treatment is education, with the systematic identification of trigger factors with a symptom diary.  Regulation of lifestyle is often the key, but the good news is that simple lifestyle and dietary changes have been shown to help in 80-90% of patients! Medication is only needed in a minimal number of patients. 

(Sourced by Meniere’s Society (UK)