The disorder

Clinical features

Vestibular migraine has no single signature symptom — it is recognised by a constellation: episodic vestibular symptoms of the right duration, a migraine link, and supportive clues such as motion sensitivity and visual dependence.

The vestibular symptoms

Trainee

The Bárány classification recognises several qualifying vestibular symptoms: spontaneous vertigo (internal or external), positional vertigo, visually-induced vertigo, head-motion-induced vertigo, and head-motion-induced dizziness with nausea.2 Spontaneous vertigo is the most frequent; the protean mix is itself a clue.

Tap a bar for detail. Many patients report several types across different attacks.

Duration — the 5 min – 72 h window

Attacks must last 5 minutes to 72 hours to qualify, of at least moderate intensity.1This window is the single most useful discriminator at the bedside: seconds-long spells point to BPPV, and the 20-minute-to-12-hour band with ear symptoms points to Ménière’s. See where VM sits against its mimics:

VM qualifying windowBPPVTIAVestibular migraineMénière'sPPPD1 s1 min5 min1 h12 h72 hattack duration (log scale)

The migrainous features

During the vertigo, look for any one of: a migrainous headache (≥ 2 of unilateral, pulsating, moderate–severe, or worse with activity); photophobia and phonophobia together; or visual aura.1 These need accompany only half of the episodes — and the headache itself may be absent, the vertigo standing in for it.

The visual aura is the most recognisable migrainous feature — a shimmering, expanding zigzag that satisfies criterion C on its own:

Fixate the cross — the aura drifts into peripheral vision over minutes.
A scintillating scotoma with a fortification spectrum: a shimmering zigzag arc that expands from near fixation toward the periphery over 20–60 minutes, often leaving a temporary blind spot. Fully reversible visual aura is one of the migrainous features that satisfies criterion C.

The arc of an attack

An attack often unfolds in phases — premonitory symptoms, an optional aura, the vestibular attack itself, and a postdrome. Step through them; note that the headache may never arrive.

Vestibular attack ± headache · 5 min – 72 h

Vertigo of any qualifying type with nausea, lasting 5 minutes to 72 hours. Migrainous features (photophobia + phonophobia, a migrainous headache, or aura) accompany ≥ 50% of attacks — but the headache may be absent, the vertigo standing in for it.

Triggers

VM attacks share the familiar migraine precipitants. Identifying and moderating a patient’s own triggers is the foundation of management, so it is worth eliciting them explicitly:

Lifestyle & routine

  • Stress / let-down
  • Sleep disruption
  • Skipped or irregular meals
  • Dehydration

Dietary

  • Caffeine excess / withdrawal
  • Alcohol (especially red wine)
  • Aged cheese, cured meats
  • MSG / processed foods

Hormonal

  • Menstruation / hormonal shifts

Environmental

  • Weather / barometric change
  • Visual overload, bright/flickering light
  • Strong smells

Key points

  • Vestibular symptoms are protean — spontaneous, positional, visually- or head-motion-induced.
  • Qualifying attacks last 5 minutes to 72 hours, of at least moderate intensity.
  • Migrainous features (headache, photo/phonophobia, or aura) accompany ≥ 50% of attacks.
  • Motion sensitivity, visual dependence and a migraine family history are supportive, not diagnostic.