(Bookmarks unavailable — private browsing?)
Central· Onset: Episodic; 5 min–72 h · Duration: Episodic, recurrent
Vestibular migraine
Overview
Summary
The most common cause of recurrent spontaneous vertigo — often misdiagnosed as Ménière's. Bárány/IHS criteria: ≥5 episodes vestibular symptoms (5 min–72 h) + current or past migraine + migraine features during ≥50% of episodes.
Diagnostic criteria
See the Bárány Society / clinical practice guideline papers[10,11] listed on the references page for the consensus diagnostic framework used in this profile.
Epidemiology
1-year prevalence ~3% adults. F:M = 3:1.
Pathophysiology
Multifactorial — trigeminovascular activation, calcitonin gene-related peptide release, cortical spreading depression, central sensitization. Vestibular pathways overlap with migraine pain pathways.
Prognosis
Variable; many improve with prophylaxis. Often lifelong.
Key examination findings
- ◆During attack: any pattern is possible — spontaneous, gaze-evoked, positional, central-pattern nystagmus all reported.
- ◆Headache, photophobia, phonophobia, visual aura concurrent with vertigo in ≥50% of episodes.
- ◆Between attacks: typically normal exam.
Investigations
- ▸Diagnosis is clinical (Bárány/IHS criteria).
- ▸Audiogram normal or with mild non-fluctuating SNHL.
- ▸MRI to exclude posterior fossa pathology in atypical cases.
Management
- ●Lifestyle: sleep regularization, hydration, trigger avoidance.
- ●Acute: triptans, NSAIDs, antiemetics.
- ●Preventive (≥4 episodes/month): topiramate, propranolol, amitriptyline, venlafaxine, flunarizine, candesartan.
- ●CGRP monoclonal antibodies are increasingly used; evidence emerging.
Clinical pearls
- ★Sensitivity to motion between attacks (mal de débarquement-like) is very common.
- ★Coexistence with anxiety/PPPD is common — screen and treat both.