Module 11 · Disease pages

Vestibular migraine

Episodic vestibulopathy with usually normal vHIT
Clinical vignette
A 38-year-old woman with a 20-year history of migraine with visual aura describes episodes of disequilibrium and head-motion-triggered visual disturbance lasting hours, sometimes days. She has had three such episodes in the past year. Half her vestibular spells are accompanied by headache, half are not. Between spells she is well. Her interictal vHIT is unremarkable.
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What it is

Vestibular migraine (VM) is one of the commonest causes of episodic vertigo, with a population prevalence of around 1%. Diagnostic criteria, jointly published by the Bárány Society and the International Headache Society in 2012[Lempert T 2012], require at least five episodes of vestibular symptoms (spontaneous or positional vertigo, disequilibrium, head-motion intolerance) of moderate or severe intensity lasting 5 minutes to 72 hours, with at least 50% of episodes accompanied by migrainous features (headache, photophobia, phonophobia, visual aura), in a patient with a current or past history of migraine.

Interictal vHIT

Between vestibular episodes, vHIT in vestibular migraine is typically normal. This is clinically useful: a patient with episodic vertigo, prior migraine history, and a normal interictal vHIT fits the picture. Minor asymmetries are common in healthy controls, and small interictal vHIT findings in VM should not be over-interpreted.

Interictal vestibular migraine — six-canal panel
0100200R latg=0.920100200L latg=0.930100200R antg=0.870100200L antg=0.880100200R postg=0.850100200L postg=0.86
Normal six-canal vHIT in interictal vestibular migraine. Subtle bilateral asymmetries are common and not diagnostic.

Ictal vHIT

During an acute vestibular migraine attack, the picture is more variable. Young et al. reported the largest case series of ictal vestibular testing in VM[Young AS 2021]: approximately 20% of patients had mild ictal vHIT gain reduction, usually bilateral and small in magnitude, with prominent associated central oculomotor signs (spontaneous nystagmus, gaze-evoked nystagmus, positional nystagmus that doesn't fit any canal plane). The ictal picture often resembles a central, rather than peripheral, vestibular syndrome.

The differential

Vestibular migraine, Meniere disease, and posterior-circulation TIA can all present with episodic vertigo, and the distinction matters because the treatment differs. A useful three-way comparison:

  • Meniere disease: caloric–vHIT dissociation on the affected side, with low-frequency hearing loss. Lasts 20 minutes to 12 hours.
  • Vestibular migraine: normal interictal testing in most patients, headache or migrainous features in > 50% of episodes. Episodes 5 min to 72 hr.
  • Posterior-circulation TIA: often brief (minutes), in patients with vascular risk factors, sometimes with brainstem or cerebellar signs in the moment. vHIT typically normal both ictally and interictally — and that's the diagnostic alarm bell, because an isolated brief episode of vertigo with normal vestibular testing in an older adult with vascular risk warrants imaging.

Key teaching points

  • Interictal vHIT is typically normal; minor asymmetries are not diagnostic.
  • Ictal vHIT can show mild bilateral gain reduction with central oculomotor signs; the picture is more central than peripheral.
  • VM and Meniere overlap in up to 30% of patients; the diagnoses are not mutually exclusive.
  • Stereotyped repeated attacks in a young patient with migraine history support VM; a first attack in an older patient with vascular risk warrants imaging.

References

  1. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, Bisdorff A, Versino M, Evers S, Newman-Toker D. Vestibular migraine: diagnostic criteria. Journal of Vestibular Research 2012;22:167–72. doi:10.3233/VES-2012-0453
  2. Young AS, Nham B, Bradshaw AP, Calic Z, Pogson JM, D'Souza M, Halmagyi GM, Welgampola MS. Clinical, oculographic and vestibular test characteristics of vestibular migraine. Cephalalgia 2021;41:1039–52. doi:10.1177/03331024211006042
  3. Halmagyi GM, Chen L, MacDougall HG, Weber KP, McGarvie LA, Curthoys IS. The video head impulse test. Frontiers in Neurology 2017;8:258. doi:10.3389/fneur.2017.00258
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