Vestibular migraine
An SVV that fluctuates with the migraine cycle — and that normalises faster than Ménière’s between episodes.
Expected SVV signature
| Phase | SVV |
|---|---|
| Active vestibular migraine attack | Mild tilt (1–4°), direction inconsistent across episodes |
| Inter-ictal | Usually normal |
| After several attacks | May have small variability increase even between episodes |
Vestibular migraine produces transient, often modest SVV abnormalities. Unlike Ménière’s, the direction of the tilt is not reliably ipsilesional — successive attacks may tilt left, right, or normalise entirely. This is consistent with the proposed pathophysiology of cortical and brainstem hyperexcitability rather than a fixed labyrinthine lesion[8].
Why direction matters
A patient with episodic vertigo whose SVV tilts to the same side on every attack is more likely to have a peripheral lesion (Ménière’s, recurrent vestibulopathy) than vestibular migraine. Conversely, a patient whose attacks tilt the SVV inconsistently — sometimes left, sometimes right, sometimes normal — fits the vestibular migraine pattern.
The Bárány Society diagnostic criteria[8] do not include SVV as a required test, but SVV trends across multiple attacks can support the diagnosis when other features are equivocal.
Clinical caveats
The most important diagnostic role for SVV in vestibular migraine is exclusion: a large, consistent ipsiversive tilt argues against migraine and for a peripheral or central structural lesion. SVV is not a tool to diagnose migraine — it is a tool to exclude its mimics.
Some patients carry both vestibular migraine and Ménière’s disease. Serial SVV combined with serial audiometry helps separate the contributions.
Companion findings
- Headache fulfilling migraine criteria, often (but not always) accompanying the vertigo
- Photophobia, phonophobia, motion sensitivity
- Caloric and VEMP testing usually normal between attacks
- MRI normal — vestibular migraine is a clinical diagnosis