When most people think of migraines, they imagine terrible headaches that are often worsened by light or bright noise. But there are several different types of migraines, one of which is called vestibular migraine. Vestibular migraines are characterized primarily by vertigo (a sensation of spinning), unsteadiness or lack of balance, sensitivity to motion, and muffled hearing or tinnitus (ringing in the ears).
It’s thought that around 10 percent of people with migraines suffer from the vestibular variety.
The vestibular system is that part of the inner ear, which tells us where we are in space in three dimensions. If you’ve ever spun in circles rapidly and then stopped, you know what happens when your vestibular system isn’t working properly.
Also called a migraine associated with vertigo (MAV), or migrainous vertigo, vestibular migraine is a common cause of sudden vertigo (dizziness)—that is, feeling that you are spinning or the world is spinning around you.
Symptoms of vestibular migraines can include one or more specific types of vertigo, including:
- Spontaneous vertigo: The feeling that you are spinning or the room is spinning around you comes on suddenly, without any trigger.
- Positional vertigo: This kind of vertigo occurs when you move or turn your head to a different position.
- Visually-induced vertigo: This type occurs in response to watching a moving object.
- Head-motion-induced vertigo: This is vertigo caused by the ongoing movement of your head.
The causes of migraine disease are generally not well understood, and causes of vestibular migraine are even less so. The belief is that abnormal brainstem activity changes how we normally interpret our senses, including pain, and alters blood flow through the arteries in the head as well.
There are mechanisms thought to be activated that link the trigeminal system (a part of the brain activated during migraines) to the vestibular system.
The association between hemiplegic migraine and episodic ataxia type 2 with mutations in the CACNA1A gene have raised the question of a possible connection between vestibular migraines and abnormalities in this gene. Other mutations in the ATP1A2 and SCN1A genes have also been studied in patients with vestibular migraines, but without a conclusive relationship so far.
All of these genes are related to ion channels that control how electricity travels in the brain.
Vestibular migraines usually occur in people with an established history of common migraines—also called migraine without aura—yet it’s important to note that vestibular migraines are underdiagnosed.
Like other forms of a migraine, vestibular migraine is more common in women than men. These migraines often make their appearance between the ages of 20 and 40 but can begin in childhood. For women, a worsening of symptoms is often noted in the pre-menstrual period. Vestibular migraines are known to run in families.
To make the diagnosis of a vestibular migraine, there are certain criteria that must be met. The diagnosis is usually made based on your history, your symptoms, the degree of your symptoms, the length of your episodes, and your history of migraines in the past.
Most of the time, a physical exam, as well as laboratory tests and imaging studies, are normal. While 40 percent of people with migraines have some vestibular symptoms, these specific symptoms must be present to diagnose vestibular migraines, per the Bárány Society’s Classification of Vestibular Symptoms:
- A history of migraine symptoms (such as a throbbing headache) within a few hours of the onset of dizziness at least 50 percent of the time
- At least five episodes lasting from five minutes to 72 hours
- No other cause that could explain the symptoms
- The presence of other symptoms in addition to vestibular symptoms, including a visual aura (for example, seeing bright lights), sensitivity to motion, photophobia (light sensitivity), and phonophobia (sound induced discomfort)
Other possibly dangerous causes of dizziness must be ruled out before the diagnosis can be made. These include:
- Benign positional vertigo: Benign positional vertigo is a form of vertigo that is thought to be caused by calcium deposits within the inner ear. The medical term for these deposits is otoconia.
- Vestibular neuritis: Vestibular neuritis, also called labyrinthitis, is inflammation of the vestibulocochlear nerve. The vestibulocochlear nerve is responsible for transmitting information about sound and your body’s position to the brain.
- Basilar migraine: A basilar migraine is a related type of a migraine that also causes vertigo but usually resolves by early adulthood. The term basilar refers to the basilar artery, which supplies much of the brainstem—including centers for balance—with blood. Unlike a vestibular migraine, basilar migraine can cause other symptoms such as double vision, slurred speech, hearing changes, clumsiness, sensory changes, and even loss of consciousness.
- Meniere’s disease: Meniere’s disease is a disorder of the inner ear that causes both vertigo and tinnitus. While Meniere’s may be confused with a vestibular migraine, it’s not uncommon for someone to have both disorders. About 45 percent of people with Meniere disease have at least one migraine-type symptom during attacks of vertigo, and there’s an increased risk of a migraine in people with Meniere’s. This suggests that the two conditions may be closely linked.
- Panic disorder: People with a migraine have a 16 percent lifetime chance of developing a panic disorder—a risk that is four times higher than in people without migraine. Both conditions can cause a sense of dizziness. Panic attacks can also cause chest pain, chills, nausea, a feeling of choking, sweating, numbness, tingling, and more. In fact, it’s not uncommon for people to have a migraine, anxiety, and problems with balance. This is called migraine-anxiety related dizziness.
- Motion sickness: People with migraine of all types are also more likely to suffer from motion sickness, again suggesting a connection between the vestibular system and migraines.
- Brainstem stroke or transient ischemic attack
Treatment and Prevention
The treatment of a vestibular migraine is similar to other migraine therapies and usually includes a combination of several treatment modalities. With regard to medications, oftentimes the drugs that relieve dizziness do not improve headaches and vice versa.
Treatments and prevention strategies include:
- Avoidance of triggers: One of the first and most important steps is to recognize (and avoid, when possible) anything that triggers migraines. This may include certain foods, sleep loss, or bright lights for starters. Visual motion may sometimes trigger a vestibular migraine (think of looking out a car window while riding).
- Lifestyle measures: From sleep hygiene to habits, lifestyle measures can make a big difference for people living with migraines. Many people with migraines, for example, find it helpful to awaken and go to sleep at the same time each day, even on weekends.
- Acute migraine medications: Medications to treat acute migraine episodes include triptans, including Relpax (eletriptan), Imitrex (sumatriptan), and several others in this class.
- Chronic migraine medications: There are several classes of medications that may be tried in order to reduce the number or frequency of migraine episodes. These can include anti-seizure medications such as Neurontin (gabapentin), beta-blockers, tricyclic antidepressants, calcium channel blockers, and more.
- Nausea and dizziness medications: Antiemetics such as Thorazine (chlorpromazine) or Reglan (metoclopramide) are useful for controlling nausea; Antivert (meclizine) is used for dizziness.
- Behavioral approaches: Behavioral therapies for a migraine, such as relaxation therapy, cognitive behavioral therapy, and biofeedback can be an important part of treatment.
- Physical therapy: Physical therapy can help control instability while walking with a vestibular migraine.
A Word From Tips For Healthy Living
Vestibular migraines can have a very significant impact on your life. Due to this, it’s important to create a comprehensive treatment plan if you experience them, including not only medications, lifestyle changes, and behavioral approaches, but also the avoidance of triggers.
It can be frustrating coping with these symptoms, and you may feel isolated because of them. There is a large community of people you can turn to for tips and advice. You may have a support group in your community, but there are many online vestibular migraine support communities available as well.