Vestibular migraine

If migraine’s making you dizzy, you’re not alone

What is vestibular migraine?

Migraine and dizziness go together for many people. Around 40 per cent of migraine sufferers will experience vertigo or balance disturbances before an attack or as the main symptom – this is known as vestibular migraine.

The word vestibular relates to the inner ear, which is important for our sense of balance.

Vestibular symptoms are often classified as ‘migraine-associated dizziness’, but dizziness is just part of the story.

Those affected by vestibular migraine will have some of the following symptoms:

• Feeling like your balance is disturbed
• Dizziness and a sense that the room is spinning (vertigo)
• Feeling particularly uncomfortable or nauseous when moving
• Possibly along with other migraine-related symptoms, such as sensitivity to light or noise, headache, disorientation and vomiting

When the headache is not the main feature, it can be easy to miss the signs of vestibular migraine, and so many people may not be correctly diagnosed.

There is a link between vestibular migraine and other conditions related to vertigo (such as paroxysmal vertigo in childhood and recurrent benign positional paroxysmal vertigo (BPPV) in adults), but the relationship isn’t well understood.

When should I suspect vestibular migraine?

Vestibular migraine is often misdiagnosed as BPPV or acute neuronitis/labyrinthitis (a viral infection of the inner ear causing similar symptoms). It will not respond to traditional vertigo treatments such as head movements or to medications like prochlorperazine and betahistine.

The headache symptoms are often missed and, since nausea and vomiting are also common features in other vertigo-related conditions, migraine can be overlooked.

But where other migraine-related features are present, such as sensitivity to light, sound, smell, touch and movement, memory loss, slowing of thoughts or headache, vestibular migraine should be suspected. The absence of headache doesn’t rule out migraine as a cause.

Unfortunately, as with all migraine, there are no tests to confirm the diagnosis objectively.

How can it be treated?

Vestibular migraine tends to be stubborn to treat.

Managing triggers should be the first-line treatment for any migraine: eating regularly, having routine sleep, minimising or managing stress and managing hormonal variations are all examples of lifestyle measures which can be helpful. See our How to live with migraine factsheet for more.

Use of anti-vertigo medication (prochlorperazine and betahistine) on a regular basis should be avoided, not only because they are ineffective for vestibular migraine, but also since they can cause over-sensitisation of the balance centres in the brain if they are used too often, leading to persistent vertigo or balance issues.

Specialist physiotherapy is frequently used to treat those with vertigo symptoms. Unfortunately, in the case of vestibular migraine this is often ineffective and, in some circumstances, can actually make symptoms worse.

Migraine preventatives can be beneficial for vestibular migraine, as they are in more common forms of migraine. If you have more than eight days a month with symptoms, a trial of one of these medications for at least six weeks at the optimum dose can be helpful in reducing the severity and frequency of attacks. The first line treatment is usually amitriptyline or nortriptyline, started at a low dose and increased slowly to a maximum of 50 to 75mg at night.

How about nerve blocks for vestibular migraine?

Studies show that use of greater occipital nerve (GON) blocks can help to reduce symptoms of dizziness. This is an injection of mixed steroid and local anaesthetic. Find out more about GON blocks here.

Book an appointment with the experts: review the best treatment options for vestibular migraine with a leading headache specialist. Beat the misery of migraine and get back to living. Book your consultation through the National Migraine Centre now.