Vestibular Migraine

1. 0:00Vestibular migraine is the most common cause of recurrent spontaneous vertigo in neurology clinics, and probably the most under-recognised. The diagnosis is purely clinical — there is no biological marker, no signature test result, no MRI finding. The Bárány Society and the International Headache Society wrote the criteria together in 2012, with a literature update in 2022. The criteria themselves are unchanged.
2. 0:30Definite vestibular migraine requires four things. First, at least five episodes of moderate or severe vestibular symptoms lasting five minutes to seventy-two hours. Second, a current or past history of migraine with or without aura by ICHD criteria. Third, migraine features — headache, photophobia and phonophobia, or visual aura — in at least half of the vestibular episodes. Fourth, exclusion of other vestibular and headache diagnoses.
3. 1:10Probable vestibular migraine relaxes the third criterion: the episodes meet the duration and intensity requirements, but only one of the migraine criteria is met — either the history of migraine, or migraine features in the episodes, but not both.
4. 1:40Vestibular migraine differs fundamentally from every other disease in this atlas. It is a central disorder of visuo-vestibular integration rather than a peripheral end-organ disease. Vestibular testing in vestibular migraine is heterogeneous: roughly half of patients have mild abnormalities, half have none, and the pattern rarely localises the way it does in neuritis or Ménière's. The vHIT is usually normal even when the patient is severely symptomatic.
5. 2:15DVA in vestibular migraine reflects the central pathophysiology. It can be abnormal in all four directions — left, right, up, and down — rather than the directional asymmetry seen in unilateral peripheral disease. The pattern is symmetric but the magnitude is typically modest. This is the head-motion intolerance and visual motion sensitivity that migraine patients describe between attacks, made measurable.
6. 2:45Two practical points. First, vestibular migraine and Ménière's disease overlap clinically in the first year — the patient with episodic vertigo and aural symptoms may meet either diagnosis. The audiogram and the Mavrodiev 2024 caloric–vHIT dissociation help distinguish, but time and serial assessment matter. Second, vestibular migraine often coexists with anxiety and persistent postural-perceptual dizziness. Recognise these overlaps — treating only the vestibular component misses half the picture.

What is vestibular migraine?

Vestibular migraine (VM) is the second most common cause of recurrent vertigo after benign paroxysmal positional vertigo, and the most common cause of spontaneous recurrent vertigo in neurology clinics. It affects approximately 1% of the general population and accounts for about 11% of patients in tertiary dizziness clinics.³⁸

Unlike every other disease in this atlas, vestibular migraine is not an end-organ disorder. The vestibular system itself is structurally intact. The pathophysiology is central — abnormal processing of vestibular and visual motion signals in the brain, related mechanistically to migraine itself. This is why the diagnosis is purely clinical, and why peripheral vestibular tests (vHIT, calorics, VEMPs, even most DVA assessments) are typically normal or only mildly abnormal.^38,39

Bárány Society / IHS 2012 criteria

The criteria were jointly formulated by the Bárány Society's Classification Committee and the International Headache Society's Migraine Classification Subcommittee in 2012, with a literature update in 2022. The criteria themselves are unchanged between the two documents. Vestibular migraine is recognised in the appendix of ICHD-3 as a condition needing further research.^38,39

Definite vestibular migraine

All four of:

1. At least five episodes of moderate or severe vestibular symptoms (vertigo, spontaneous or positional or head-motion-induced; or head-motion-induced dizziness with nausea), lasting 5 minutes to 72 hours.
2. Current or previous history of migraine with or without aura, per ICHD criteria.
3. One or more migraine features accompanying at least 50% of the vestibular episodes:
   • headache with at least two of: unilateral location, pulsating quality, moderate/severe intensity, aggravation by routine activity
   • photophobia and phonophobia
   • visual aura
4. Not better accounted for by another vestibular or ICHD diagnosis.

Probable vestibular migraine

Episodes meeting criterion 1 (≥5 episodes, 5 min–72 h, moderate or severe), only one of criteria 2 and 3 (migraine history or migraine features per episode but not both), and exclusion of other diagnoses.

The duration distribution

Episode duration in vestibular migraine is famously variable. The consensus document reports:

• ~30% of patients: episodes lasting minutes
• ~30% of patients: episodes lasting hours
• ~30% of patients: episodes lasting several days
• ~10% of patients: very short attacks of seconds, triggered by head motion, visual stimulation, or positional change. The "episode" in this group is defined as the total period during which short attacks recur.³⁸

This spread alone places vestibular migraine in the differential for nearly any episodic vertigo pattern other than the truly fixed windows (BPPV under 60 seconds; Ménière's 20 minutes to 12 hours).

The vestibular test battery — heterogeneous and unhelpful

Inter-ictal vestibular testing in VM is heterogeneous. About half of patients show mild abnormalities, but the pattern rarely localises. The 2012 consensus is explicit: "Vestibular findings and testing results can be pathological, particularly during or shortly after an episode, but they are not sufficiently specific to serve as diagnostic criteria."³⁸

Recent ictal-versus-interictal work (2025) found that VOR function on vHIT remained normal across attack phases, while subjective visual vertical deviation was significantly worse ictally — consistent with central rather than peripheral dysfunction.

Profound abnormalities — bilateral vestibular loss, severe unilateral SNHL, complete unilateral vestibular loss — should prompt re-evaluation. They are not part of the VM picture, and they suggest another diagnosis or a comorbid one.³⁸

The DVA pattern in detail

DVA findings in vestibular migraine reflect the central pathophysiology. Three patterns are worth recognising:

• Symmetric mild loss in all four directions — left, right, up, down. Sevimli and colleagues (2022) showed significant DVA loss in all four positions in twenty migraine patients compared with controls, interpreted as evidence of impaired visuo-vestibular cortical integration rather than peripheral VOR failure.⁴⁰ The shape of the pattern resembles bilateral vestibulopathy (no asymmetry), but the magnitude is much smaller (≤0.2 logMAR) and the underlying mechanism is entirely different.
• Ictal worsening with inter-ictal recovery. DVA measured during an attack is worse than between attacks — but most testing is done in the inter-ictal phase, where it appears modestly or not at all abnormal.
• Visual motion sensitivity correlate. The DVA asymmetry between active and passive head motion paradigms is sometimes wider in VM than in controls, fitting with the head-motion intolerance these patients describe. This is more a research finding than a clinical one at present.

Distinguishing VM from Ménière's disease

Vestibular migraine and Ménière's disease overlap clinically in the first year of symptoms, and the two diseases co-occur more often than chance — migraine is more common in Ménière's patients than in healthy controls, and bidirectional inheritance has been described.^32,38 Distinguishing the two matters because management differs.

Useful discriminators:

• Audiogram. Definite Ménière's requires audiometrically documented low- to mid-frequency SNHL on the affected side. VM does not produce sustained SNHL — fluctuating hearing in VM tends to be transient and recovers fully.^32,38
• Caloric–vHIT pattern. The Mavrodiev 2024 study in 2,101 patients established that the dissociation pattern (abnormal caloric, normal vHIT) is far more common in Ménière's than in VM. In a patient where the diagnosis is uncertain, this pattern argues for Ménière's.³⁴
• Migraine features in episodes. Photophobia and phonophobia during attacks favour VM. Auditory symptoms (fullness, tinnitus, distortion) localised to one ear favour Ménière's.
• Episode duration distribution. Ménière's episodes cluster at hours; VM episodes spread from minutes to days. The very-short and the very-long ends of the duration spectrum favour VM.³⁸

When the picture is genuinely mixed and both criteria are met, the Bárány Society allows diagnosis of both conditions if the patient has two distinguishable types of episodes. A future revision may include an overlap syndrome category.³⁸

Other differential diagnoses

• BPPV. Vestibular migraine with positional features can mimic BPPV. In VM, the positional nystagmus is usually persistent (not paroxysmal) and does not align with a single canal; symptomatic episodes are shorter and more frequent than in BPPV.³⁸
• Persistent postural-perceptual dizziness (PPPD). The chronic between-attack dizziness in VM can evolve into PPPD — the two coexist in many patients. PPPD is characterised by persistent (≥3 months) dizziness exacerbated by upright posture, self-motion, and complex visual stimuli.
• Vestibular paroxysmia. Brief (seconds) attacks of vertigo recurring many times per day, typically responsive to carbamazepine. The 10% of VM patients with attacks lasting seconds are the differential challenge here.
• Transient ischaemic attacks. Sudden onset, vascular risk factors, total history of attacks less than one year, and evidence of vertebrobasilar pathology favour TIA over VM, especially in older patients.³⁸
• Anxiety-related dizziness. Common comorbidity with VM (over 50% in some series). Situational provocation, autonomic activation, and avoidance behaviour are clues. Treat both.³⁸

Management implications for the test request

When VM is the leading diagnosis, the role of vestibular testing shifts from establishing the diagnosis to excluding alternatives. Three orders worth considering:

• MRI of the brain and IAC — to exclude structural disease (schwannoma, demyelination, posterior fossa lesion). VM does not have an MRI signature.
• Audiometry — to exclude Ménière's disease and to document the baseline. Repeat during a symptomatic period if the initial audiogram is normal.
• vHIT and caloric — to exclude unilateral or bilateral peripheral vestibulopathy. The classic "VM" result is both being broadly normal.

Reading the report

A patient with ≥5 episodes of moderate-to-severe vertigo lasting 5 minutes to 72 hours, a migraine history, migraine features in at least half of the episodes, and exclusion of alternative diagnoses, meets the Bárány 2012 definite criteria for vestibular migraine.³⁸ DVA, vHIT, caloric, and audiometry contribute by what they exclude, not by what they confirm. A broadly normal vestibular test battery in the right clinical context supports the diagnosis precisely because it makes alternatives less likely.^38,39