Disorders · Introduction
Vestibular migraine
The commonest cause of recurrent spontaneous vertigo — and one of the most missed. The headache and the vertigo need not occur together, the ears stay quiet, and the diagnosis rests on a pattern plus a migraine link rather than any single test.
What vestibular migraine is
Vestibular migraine is migraine that shows up as dizziness or vertigo instead of — or as well as — headache. Attacks last anywhere from a few minutes to a couple of days, and often come with migraine clues such as sensitivity to light and sound. Hearing is not affected. It is common, and very treatable.
VM is defined by recurrent vestibular symptoms in someone with a current or past history of migraine, with migrainous features (photophobia/phonophobia, visual aura, or a migrainous headache) accompanying the attacks.1 Crucially, the vertigo and the headache need not coincide, and the migraine history may have remitted years earlier.
VM is the great mimic of episodic vertigo: it overlaps clinically with Ménière’s disease, BPPV and posterior-circulation events, and remains a clinical diagnosis of inclusion-plus-exclusion under the Bárány Society / IHS criteria.1,4 The clinician’s task is to recognise the episodic pattern, establish the migraine link, and actively exclude the audiovestibular and vascular look-alikes.
Vestibular migraine by the numbers
VM has a lifetime prevalence of around 1% and accounts for a large share of patients in dizziness clinics. It shows a clear female predominance and is the leading cause of recurrent spontaneous vertigo.2,3
Sex ratio
female male
Age of onset
peak onset in the thirties–forties
How this chapter is organised
- Pathophysiology & mechanisms — the trigeminovascular and central-vestibular model, and why headache and vertigo decouple.
- Clinical features — the attack phenotype, triggers, and the supportive (non-diagnostic) clues.
- Diagnostic criteria — the Bárány Society criteria, with an interactive definite-vs-probable checker.
- Differential diagnosis — separating VM from Ménière’s, BPPV, vestibular paroxysmia, TIA and PPPD.
- Treatment & prevention — lifestyle and trigger management, acute relief, and preventive pharmacotherapy.
Key points
- VM is the commonest cause of recurrent spontaneous vertigo, with a female predominance.
- Attacks last 5 minutes to 72 hours; the headache and vertigo need not coincide.
- Hearing is preserved — progressive low-frequency loss should redirect you to Ménière’s.
- Diagnosis follows the Bárány Society criteria: definite vs probable VM.
- Management is behavioural first (triggers, lifestyle), with preventives for disabling disease.