Vestibular migraine: the link between migraine and dizziness

Vestibular migraine is a form of migraine in which dizziness or vertigo is the main symptom, instead of or alongside headache. The balance system becomes oversensitive, just as the brain does in other forms of migraine. It is one of the most underdiagnosed forms of migraine, and it can be treated.

The link between migraine and dizziness is often missed. You get out of bed and the room spins. Or you are walking through the supermarket and suddenly feel unsteady on your feet. Many clinicians, and many patients, do not think of migraine when someone is dizzy. So you may see your GP, an ear specialist and perhaps a heart specialist, each finding nothing wrong. Yet once the right diagnosis is made, a range of treatment options opens up.

What is vestibular migraine?

Vestibular migraine is a form of migraine that involves the balance system. Your brain controls your balance through the vestibular system, a network of nerves and sensors in your inner ear that signals where your head is in space. In vestibular migraine this system becomes oversensitive, just as happens with other migraine symptoms.

Importantly, vestibular migraine does not have to come with headache. Many people with vestibular migraine have only dizziness: no pain and no other obvious migraine symptoms. That makes it very difficult to diagnose.

What are the symptoms of vestibular migraine?

Not everyone has all of the symptoms below; migraine is different for everyone. The most common are:

• Vertigo: a spinning sensation, as if you or the room are turning. It can be mild or severe.
• Unsteadiness: you feel unstable on your feet, as if standing on a boat.
• Sensitivity to movement: turning your head, looking down or even moving your eyes quickly makes the dizziness worse.
• Sensitivity to light and sound: bright light and loud noise can make the dizziness worse.
• Nausea: sometimes to the point of vomiting, and sometimes worse than the dizziness itself.
• Brain fog and tiredness: feeling hazy, and exhausted after an attack.

What does a vestibular migraine attack feel like?

Many people describe it as the world moving while they stand still, or the other way round. Sometimes you have to sit down because you are afraid of falling. Many people feel better when they keep still. Afterwards you may feel hazy, as if you are not quite present, and completely drained.

How long it lasts varies a great deal:

• Short attacks: minutes to hours
• Long attacks: hours to days
• Chronic vestibular migraine: some people feel more or less dizzy for months on end

What triggers a vestibular migraine?

The triggers are largely the same as for other forms of migraine, and they differ from person to person. Commonly reported ones include hormonal changes around a period, too little or irregular sleep, stress, and skipped meals. Busy visual surroundings, such as supermarket aisles or scrolling screens, and motion in a car or on a boat can also bring on symptoms for some people. As with other migraine, avoiding every possible trigger is rarely realistic or necessary.

Why is vestibular migraine so often missed?

Dizziness can have many causes, such as an inner ear problem, low blood pressure or anxiety, so a clinician does not always think of migraine straight away. And because vestibular migraine does not always come with headache, you say "I am dizzy" and migraine does not come to mind.

Add to this that many patients do not know that dizziness and migraine can be related, and the pattern becomes clear: vestibular migraine is underdiagnosed.

How do you recognise vestibular migraine?

These signs point towards vestibular migraine:

• you have had episodes of dizziness for years;
• the dizziness does not follow an obvious seasonal or situational pattern;
• you have become more careful with movement because you are afraid of falling;
• movement makes the symptoms worse;
• you also have other migraine-related symptoms: nausea, sensitivity to light or sound, brain fog;
• the attacks are episodic: they come and go.

If this sounds familiar, it is worth discussing your symptoms with a migraine specialist. Like other migraine diagnoses, vestibular migraine is diagnosed from your history. There is no blood test or scan that shows it, although tests are sometimes used to rule out other causes.

How is vestibular migraine different from other causes of dizziness?

BPPV (benign paroxysmal positional vertigo)

This is the condition most often confused with vestibular migraine. In BPPV, small crystals in the inner ear have come loose. Difference: BPPV symptoms come on with particular head movements, such as turning over in bed, and last seconds to a minute. Vestibular migraine episodes usually last longer, from minutes to days, and often come with other migraine symptoms.

Low blood pressure

Difference: with low blood pressure you usually feel better when you lie down. With vestibular migraine, lying down often makes little difference.

Anxiety

People with agoraphobia sometimes feel dizzy in public spaces. Difference: this happens in specific situations, while vestibular migraine occurs regardless of the situation. Dizziness and anxiety can also go together, which is one more reason to look at the whole picture.

How is vestibular migraine treated?

Diagnosis: make sure you get the right diagnosis from someone familiar with migraine. At The Migraine Clinic you can book a video consultation with a migraine specialist yourself, without a referral.

Preventive treatment: like other migraine, vestibular migraine can be prevented with medication. Options include the gepants atogepant and rimegepant and the monoclonal CGRP inhibitors erenumab, fremanezumab and galcanezumab. Research specifically in vestibular migraine is still limited, so a migraine specialist will weigh up with you what fits your situation.

Self-care: during an attack, rest in a dark room, avoid movement and drink enough.

Keep a diary: note when the dizziness occurs, how long it lasts and what else you felt.

Is vestibular migraine all in your head?

No. Many people with vestibular migraine feel they are not believed. Because it is invisible and clinicians do not always recognise it, people sometimes start to think it is anxiety or that they are imagining it. Vestibular migraine is a real neurological condition, and there are good treatments for it.

This form of migraine can seriously limit your ability to work, especially if your work involves movement, and it can shrink your social life. Many people feel isolated because they do not feel safe going out. With the right diagnosis and treatment you can get a grip on it.

When to get urgent help

Call 999 or go to A&E if you have:

• a sudden, severe headache that reaches its worst within minutes
• weakness or numbness on one side of the body
• slurred speech
• loss of vision that does not return
• sudden severe dizziness with double vision, difficulty walking or difficulty speaking
• a first aura after the age of 50
• a headache with fever and a stiff neck

If you are worried but it is not an emergency, call NHS 111.

There is hope

Vestibular migraine is sometimes missed for years. But once you have the diagnosis, a lot changes: there are treatments, and you can take your life back. Do you have episodes of dizziness without a clear cause? Take the migraine test, read about preventive medication, or find out how to start.

Written by the medical team of The Migraine Clinic.