What's a vestibular migraine?
A vestibular migraine is a neurological condition that causes episodes of vertigo or dizziness in individuals with a history of migraine. It’s considered one of the most common causes of recurring dizziness related to the inner ear and brain. Unlike typical migraines, vestibular migraines don’t always include headache. Instead, they often involve problems with balance, spatial orientation and movement perception, sometimes accompanied by nausea or visual disturbances.
The term ‘vestibular’ refers to the system in the inner ear and brain that helps control balance and eye movements. During a vestibular migraine, abnormal signals in this system can lead to a sensation of spinning, unsteadiness or swaying. These symptoms can occur with or without the classical features of migraine, such as visual aura, light sensitivity or head pain.
Vestibular migraine is still not fully understood, and diagnosis can be challenging. It often overlaps with other balance disorders such as Ménière’s disease or benign paroxysmal positional vertigo (BPPV). However, the condition is increasingly recognised and can be managed effectively with appropriate treatment.
What does it feel like?
The main symptom of a vestibular migraine is vertigo. This can feel like the room is spinning, or as though the body is moving when it is not. Some patients describe feeling off balance, lightheaded, or as if they are floating. These symptoms can come on suddenly or gradually and vary in severity.
Other possible symptoms include nausea, vomiting, sensitivity to motion, or difficulty focusing the eyes. Some people also experience visual disturbances such as flashing lights or blind spots. Unlike more traditional migraine attacks, vestibular migraines do not always cause a pounding headache. However, some people do experience a mild to moderate head pain either before, during or after the dizzy episode.
The vertigo and other symptoms may last from a few seconds to several hours, and in some cases, days. Between attacks, people often feel normal, although some may remain sensitive to motion or light for a time. The unpredictable nature of vestibular migraine can affect daily activities and may cause anxiety or avoidance of certain movements or environments.
What triggers vestibular migraines?
Vestibular migraines, like other types of migraine, are thought to be linked to changes in the brain's electrical activity and how it processes sensory information. Specific triggers can vary from person to person but often include similar factors known to affect traditional migraines.
Common triggers may include stress, sleep disturbances, hormonal fluctuations (such as during menstruation), dehydration, skipping meals, strong smells, bright or flickering lights, and certain foods or drinks. Caffeine, alcohol (especially red wine), and foods containing monosodium glutamate (MSG) or artificial sweeteners may also provoke symptoms.
In people prone to motion sickness or who are sensitive to visual stimuli, vestibular migraines may be triggered by travelling in a car or plane, scrolling on screens, or being in visually stimulating environments like busy shopping centres. Identifying and avoiding individual triggers can play an important role in managing the condition.
What are the different stages of vestibular migraines?
Vestibular migraines can involve several stages, although not every person will experience all of them with each episode. The pattern often mirrors that of classic migraine phases but with an emphasis on balance and dizziness.
Prodrome phase
The prodrome phase may occur hours or days before the main symptoms and includes subtle warning signs such as irritability, tiredness, stiff neck, or food cravings.
Aura phase
In the aura phase, which some people experience, there may be temporary visual or sensory changes such as flashing lights, numbness, or tingling. These signs usually last less than an hour.
Attack phase
The attack phase is where vestibular symptoms become most prominent. This typically involves vertigo or imbalance, which may be accompanied by nausea, head pressure, sound sensitivity, or vision changes. In some cases, a mild headache may also occur.
Postdrome phase
The postdrome, or recovery phase, follows the attack and may last several hours to a day. During this period, the individual may feel fatigued, mentally foggy, or unusually sensitive to movement.
Understanding these phases can help patients and clinicians recognise a vestibular migraine early and manage symptoms more effectively.
How long do vestibular migraines last?
The duration of a vestibular migraine can vary widely. Some episodes are brief, lasting just a few minutes, while others may continue for several hours or even up to three days.
Most commonly, vertigo lasts between 20 minutes and several hours. Recovery from the episode can also vary, with some individuals returning to normal quickly and others needing a day or more to feel steady again.
The frequency of attacks also differs between patients. Some people may have only a few episodes a year, while others experience them monthly or more frequently.
Recurrent or severe episodes can have a significant impact on daily life and should be evaluated by a specialist to guide appropriate management.
Can vestibular migraine be confused with other conditions?
Vestibular migraine can often be mistaken for other conditions, especially in the early stages or when headache is not present.
The following conditions can all share similar symptoms to vestibular migraines:
- Ménière’s disease;
- vestibular neuritis;
- BPPV, and;
- anxiety-related dizziness.
Detailed clinical history, physical examination, hearing tests, and sometimes imaging or balance tests may be required to rule out other causes.
Because vestibular migraine symptoms can vary so much between individuals, a diagnosis may take time and often relies on pattern recognition over repeated episodes.
This is why keeping a detailed record of symptoms and possible triggers is helpful in reaching an accurate diagnosis.
Is vestibular migraine a lifelong condition?
Vestibular migraine is typically a chronic condition, but many people experience changes in the frequency and severity of attacks over time. With appropriate management, many patients can reduce the impact of the condition and lead a normal, active life. Some may see complete resolution of symptoms, especially if they can avoid triggers and maintain preventative strategies.
Long-term follow-up may be needed, particularly for those with frequent or disabling symptoms. Regular review ensures that treatment remains appropriate and provides support in managing this often-misunderstood condition.
How are vestibular migraines treated?
There is no single test or treatment for vestibular migraine, but the condition can be managed with a combination of lifestyle changes, medication, and sometimes vestibular rehabilitation therapy.
Identifying and avoiding triggers is a key part of prevention. There are several ways to do this:
- Keeping a migraine diary may help to spot patterns and avoid situations that bring on attacks.
- good sleep hygiene;
- regular meals;
- stress reduction techniques, and;
- moderate exercise can also help reduce the frequency of episodes.
Acute attacks may be treated with medications that relieve dizziness, nausea, or migraine-related symptoms. These might include anti-nausea tablets, non-steroidal anti-inflammatory drugs, or triptans in cases where headache is also present. For frequent or severe attacks, preventative treatments may be considered. These could include medications such as beta-blockers, calcium channel blockers, or certain antidepressants or anticonvulsants that have been shown to reduce migraine frequency.
In some cases, vestibular rehabilitation – a form of physiotherapy that targets balance – may help reduce symptoms or improve motion tolerance between attacks. Treatment plans are usually individualised based on symptom severity, frequency, and co-existing conditions.
What specialist treats vestibular migraines?
Vestibular migraines are often managed through a multidisciplinary approach involving both ENT and neurological specialists. An ENT and head and neck surgeon plays an important role in excluding other inner ear disorders that can mimic similar symptoms, such as Ménière’s disease or BPPV. A neurologist may also be involved in diagnosis and ongoing treatment, especially when there is overlap with other types of migraine or neurological conditions.
Patients are typically referred to ENT or neurology clinics through their GP, particularly when episodes are recurrent or significantly affect quality of life. Audiologists and vestibular physiotherapists may also be involved in the diagnostic process and rehabilitation. Effective communication between these professionals is key to a clear diagnosis and tailored treatment.