Understanding Vestibular Migraines

Vestibular migraine, also referred to as “migraine associated vertigo,” is when a patient also experiences dizziness and imbalance. Vestibular migraine is one of the most common causes of vertigo, or the sensation of spinning or moving when you are still. Patients may also experience:

  • Light-headedness
  • Vision changes
  • Hearing changes or tinnitus (ringing or buzzing sound in your ear)
  • Headache (many patients report headaches after their dizziness has subsided)
  • Nausea, vomiting, fatigue
  • Motion sickness or sensitivity or complicated visual patterns
  • Visual auras, sensitivity to light, blurring, seeing flashing spots or lights
  • Sensitivity to light or sound
  • Difficulty with concentration or memory issues

Migraines can be described as a recurring type of headache that may occur with auras, which are sensory disturbances such as visual changes, difficulty speaking, and tingling in the arms and legs. A “common” migraine headache does not usually involve auras.

Vestibular migraines may be treated by an ENT (ear, nose, and throat) specialist, or otolaryngologist, and/or a neurologist. Because the symptoms overlap and frequently coincide with inner ear disorders (such as benign paroxysmal positional vertigo and Ménière’s disease), patients often visit several different specialists before establishing a clear diagnosis and starting appropriate treatment. Like common or classic migraines, vestibular migraine often runs in families, and women are more frequently affected than men. Vestibular migraine is also commonly linked with depression and anxiety.

How Do I Know if I Have a Vestibular Migraine?

To make a reasonable diagnosis of vestibular migraine requires a conversation with your doctor to review your medical history. However, a positive diagnosis is likely if you have at least five episodes of moderate to severe symptoms lasting between five minutes and 72 hours, and at least half of your episodes include at least one of the following three features:

  • Headache with at least two of the following four characteristics: (1) unilateral (one-sided) location, (2) pulsating quality, (3) moderate or severe intensity, and/or (4) aggravation by routine physical activity
  • Fear of or sensitivity to light and sound
  • Visual aura

What Are Common Triggers of Migraines?

Common triggers of migraines include:

  • Stress and anxiety
  • Dehydration
  • Poor sleep quality and fatigue
  • Hunger
  • Hormonal changes (such as those experienced during menopause or puberty, menstruation, or hormone therapy)
  • Motion triggers such as unexpected movement (e.g., inside a moving vehicle)
  • Complex or visually “busy” stimuli (ceiling or floor patterns, crowded environments, entertainment screens)

Certain foods can also trigger a vestibular migraine. Your doctor may recommend a diet with low levels of tyramine, an amino acid, monosodium glutamine (MSG), preservatives, caffeine, and alcohol. Your doctor may provide you with a more extensive or modified list of foods to avoid. The goal is not necessarily to abruptly stop these foods if you really enjoy them. Instead, start to moderate and gradually decrease them to help recognize your common triggers. Once your symptoms are controlled, you can slowly add back your desired foods while closely monitoring your symptoms.

Examples of trigger foods include:

  • Aged cheeses
  • Smoked or cured meats
  • Food prepared with soy sauce, vinegar, or yeast extract
  • Pickled and fermented foods (buttermilk, yogurt, sour cream)
  • Onions, olives, pickles
  • Artificial sweeteners
  • Alcohols such as heavier red wines, port wines, sherry wines, scotch, gin, and bourbon
  • Dark chocolate, cocoa, peanut butter
  • High amounts of certain fruits such as figs, red plums, bananas, citrus fruit, raisins, passion fruit
  • Excess caffeine

One method to identify triggers is to keep a daily symptom journal with details such as waking time and bedtime, foods eaten, stress levels, and additional symptoms experienced. Stress relief and improving sleep hygiene may reduce the frequency and severity of attacks.

What Are My Treatment Options?

Medications may be prescribed to prevent episodes if avoiding triggers does not help control symptoms. Preventative mediations can include a beta-blocker (e.g., propranolol), calcium channel blocker (e.g., verapamil), antidepressant (e.g., nortriptyline, venlafaxine), and/or an anticonvulsant (e.g., topiramate). Treatment with an antidepressant or anticonvulsant does not mean you have depression or seizures; they are intended to stabilize the central nervous system and raise the threshold at which attacks are triggered. Medication regimens may be tailored to your existing medical conditions. Once symptoms are controlled, medications may be weaned off and do not necessarily need to be taken forever.

Vestibular rehabilitation is a type of physical therapy that may also be recommended to treat chronic balance dysfunction. Vestibular therapy will train your brain to desensitize itself to common sensory triggers. The course of therapy is often gradually increased in its intensity and can be widely varied to combat multiple types of triggers that include movement, visual perceptions, and posture instability.

Treatment to help stop a vestibular migraine attack once it begins includes rest, observation, hydration, and medications such as anti-nausea, antihistamine, or sedatives if needed. However, the most effective way to treat vestibular migraine is preventing an attack as described above, and it is critical to recognize your triggers. Many cases can be treated with trigger avoidance alone.

What Questions Should I Ask My Doctor?

If you feel like you need to see a doctor to help control your migraine symptoms, you might consider some of these questions during your conversation:

  1. Should I keep a migraine symptom journal and what details should I track?
  2. What are my treatment options and how will they affect my existing medical condition(s)?
  3. Do I need a hearing, balance, or imaging test?
  4. Do I need to see another specialist?

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The information on ENThealth.org is provided solely for educational purposes and does not represent medical advice, nor is it a substitute for seeking professional medical care.