Identifying Early Triggers, Symptoms of Vestibular Migraine

Anatomy of human ear
Anatomy of human ear
Vestibular migraine often goes unrecognized particularly in the absence of headache.

A retrospective study recently published in Pain Medicine identified a set of clinical characteristics and triggers of vestibular migraine (VM) in the absence of a peripheral etiology for vertigo.1

VM affects an estimated 1% of the general population and is the second leading cause of vertigo (after benign paroxysmal positional vertigo).2,3 However, this condition often goes unrecognized, particularly in the absence of headache or when patients are evaluated by a clinician who is not a headache specialist. Before the 2013 publication of diagnostic criteria for VM in the International Classification of Headache Disorders 3 beta version (ICHD-3 beta), diagnostic criteria and proper terminology for the condition were unclear.

There is also “heterogeneity in clinical features of VM, in addition to the various expressions of vestibular symptoms…[which] may initiate before, during, or after the headache,” wrote the authors of the new study. Alternately, the headache may be independent of the vestibular symptoms.5 “One of the main problems is that the vestibular symptoms do not exactly match well-known external vertigo definitions, and imaging and auditory tests generally do not reveal a significant pathology,” they explained.

In the current investigation, researchers at Gazi University in Turkey conducted a retrospective review of patient records to identify clinical characteristics of patients diagnosed with VM by a headache specialist after otolaryngologist referral. The sample included 101 adult patients (mean age, 40.1±10.2 years; 86.1% women) in whom peripheral causes of vertigo and other exclusion criteria had been ruled out.

The main findings were as follows:

  • Patients’ descriptions of vestibular symptoms most commonly included: feeling as though the ground were slipping from under their feet (40.6%); the sensation of an earthquake or swaying (27.7%), or rocking on a boat (26.7%); and the feeling of falling or stepping on empty space (24.8%).
  • Vestibular symptoms lasted seconds (60.4%), minutes (32.7%), or hours (6.9%). Even when lasting only seconds, symptoms occurred with each head movement and visual stimulus.
  • The most common precipitating factors for vestibular symptoms included head/body motion (82.2%), moving visual stimuli (71.3%), passive motion (49.5%), and visually busy environments (47.5%).
  • The most common triggers for vestibular migraine were sleep deprivation (62.4%), hunger or skipping meals (53.5%), stress (48.5%), menstruation (41.6%), and infections (37.6%). Weather changes and various dietary factors were also reported as triggers.
  • The most common co-occurring conditions were sleep disorders (34.7%), depression (21.8%), and anxiety (19.8%).
  • 51.5% of patients had previously been diagnosed with Meniere’s disease.
  • Migraine prophylaxis (most often with propranolol 40 to 80 mg, duloxetine 60 mg, topiramate 50 to 100 mg, metoprolol 50 to 100 mg, and amitriptyline 25 to 50 mg) led to a greater than 50% reduction in vestibular symptom frequency in 86.1% of patients, as well as in migraine headache frequency in 97.0% of patients.
  • Although 83.2% of patients used vestibular-suppressant drugs, effectiveness of these medications were only temporary and reported by 12.9% of affected patients.

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“The descriptions of the patients fit into dizziness rather than spontaneous internal or external vertigo,” according to the authors. Because vestibular symptoms are evoked by visual and postural motion, the “central integration and processing of somatosensory, vestibular, and visual stimuli may be interrupted during migraine attacks.” Additional research will be needed to explore this possibility.

Study Limitations

The study was retrospective in nature and lacked a thorough assessment of early responses to anti-migraine medication.


  1. Vuralli D, Yildirim F, Akcali DT, Ilhan MN, Goksu N, Bolay H. Visual and postural motion-evoked dizziness symptoms are predominant in vestibular migraine patients [published online July 13, 2017]. Pain Medicine. doi: 10.1093/pm/pnx182
  2. Lempert T, Neuhauser H. Epidemiology of vertigo, migraine and vestibular vertigo. J Neurol. 2009;256(3):333-8. doi: 10.1007/s00415-009-0149-2
  3. Neuhauser H, Radtke A, von Brevern M, et al. . Neurology. 2006;67(6):1028-1033. doi: 10.1212/01.wnl.0000237539.09942.06
  4. Headache Classification Committee of the International Headache Society. The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33:629-808. doi: 10.1177/0333102413485658
  5. Dash AK, Panda N, Khandelwal G, Lal V, Mann SS. Migraine and audiovestibular dysfunction: Is there a correlation? Am J Otolaryngol. 2008;29(5):295-299. doi: 10.1016/j.amjoto.2007.09.004

This article originally appeared on Clinical Pain Advisor