Case 07 of 8 · Trainee · Vestibular migraine

Recurrent dizziness in a 34-year-old with migraine

A 34-year-old with recurrent dizziness, migraine history, normal vestibular testing.

CASE VIGNETTE

A 34-year-old woman reports a two-year history of episodic dizziness — a sensation of swaying, of the floor 'tilting', and visual hypersensitivity in busy environments such as supermarkets. Episodes last 30 minutes to several hours, occur on average twice per month, and are often accompanied by photophobia and a unilateral pulsating headache. Migraine without aura was diagnosed in her teens and is well controlled with topiramate.

Between episodes she feels well. No hearing change, no tinnitus, no aural fullness. Audiogram is normal. Bedside HIT is normal. There is no spontaneous nystagmus, no nystagmus on gaze testing, no skew.

DVA testing during a clinic visit (between episodes) shows symmetric mild loss of 0.15 logMAR in horizontal directions and 0.10 logMAR vertically. Formal vHIT shows gain 0.85 bilaterally — within normal limits. Caloric testing is normal symmetric. cVEMP and oVEMP normal bilaterally. MRI brain (performed once, two years ago) is unremarkable.

DVA SIGNATUREMild

Vestibular migraine — central pathophysiology

DVA loss: Mild symmetric in all four directions (0.10-0.15 logMAR)
Laterality: Bilateral symmetric, all directions
Asymmetry: None
Corroborating tests: Normal vHIT · normal calorics · normal VEMPs · migraine history · migraine features in episodes

Key signature: Vestibular migraine is a clinical diagnosis. Mild symmetric DVA loss in all four directions is consistent with the central pathophysiology — a disorder of visuo-vestibular integration — and does not require peripheral testing abnormalities.

Test-battery findings

DVA — horizontal	0.15 logMAR symmetric both directions
DVA — vertical	0.10 logMAR symmetric both directions
vHIT gain	0.85 bilaterally — normal
Caloric	Normal symmetric
cVEMP / oVEMP	Normal bilaterally
Audiogram	Normal
MRI brain	Unremarkable (historical)

Question

How should this clinical picture be interpreted in terms of vestibular migraine diagnosis?

References

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Vestibular migraine — central pathophysiology

Test-battery findings

Question

Further reading

References