Vestibular Migraine: Simply Not So Simple.

A recent panel summit on the topic of vestibular migraine brought out some of the major challenges we face trying to help patients. In short, the diagnosis and treatment of vestibular migraine simply is not simple.

Although vestibular migraine is getting more press these days, you can feel the remaining questions in the International Classification of Headache Disorders 3 (ICHD3), where it’s placed under the heading “Episodic syndromes that may be associated with migraine”.

You can read more about vestibular migraine here, or at the ICHD3 link above, but essentially it’s diagnosed when a patient with migraine has some vertigo and/or dizziness associated with their migraine attacks. Often the “vestibular” symptoms develop many years after other migraine symptoms started.

Of course, specialists are trying to rule out vertigo/dizziness from other causes, and make a clear connection with migraine. And there certainly is a clear connection in some patients. But when it comes to diagnosis and treatment, as the expert panel pointed out in their January 2022 report, “gaps remain”.

You can read the full report here (Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit), and there’s lots to think about. But one of the most interesting parts was how symptoms vary and actually overlap with other conditions.

In practical terms, just because vertigo and migraine often go together doesn’t mean that they’re one and the same disease, and that treatment of one will solve the other – although that may be the case for some.

One study showed only a minority of patients who experienced vertigo during their headache phase. In fact, some patients reported vestibular symptoms up to two days before the headache hit.

Then there are different types of vertigo/dizziness. Is it induced by something you see? By head movement? Is it accompanied by nausea? Does it start out of nowhere? Any of these might qualify for vestibular migraine.

Another challenge – with so many kinds of vertigo and dizziness, how do you as a patient describe the feeling – especially if it’s new to you?

Then there’s misdiagnosis, even within migraine types. Often a patient has been misdiagnosed with migraine with brainstem aura, which may also include vertigo.

Benign paroxysmal positional vertigo (BPPV) is a very common cause of vertigo (check out this fascinating video about BPPV and the very helpful book Overcoming Positional Vertigo). Then there’s Ménière’s disease, a condition of the inner ear, and mal de debarquement syndrome. Tinnitus, heading loss conditions – all these things intersect in some interesting ways. Next come psychiatric conditions, neck problems – the researchers explain:

The symptoms of these conditions may overlap with those of VM symptoms and confuse the diagnosis of VM, especially when patients with other vestibular disorders may have superimposed, secondary migraine symptoms and not have VM as a primary cause of their symptoms. Psychiatric comorbidities, including anxiety, somatoform dizziness/chronic subjective dizziness may coexist with VM as well.Furthermore, acknowledging that patients may have more than one vestibular diagnosis contributing to their symptoms is essential to providing accurate treatment and conducting accurate research.

Care Gaps and Recommendations in Vestibular Migraine

So if other conditions can exist at the same time as migraine, or even overlap with migraine symptoms, is one somehow biologically related to the other – perhaps causing or increasing the symptoms of the other?

Surprisingly, some have suggested that migraine may actually affect the inner ear biologically – in other words, physical problems in the inner ear may actually be a “complication of migraine”.

For the doctor, just being aware of these connections can go a long way. But what about the patient?

First, it has to be admitted that the road to helpful diagnosis and treatment can be long. But don’t give up! If one condition can actually make the other worse, the best thing to do is to see a specialist and get treatment as soon as possible.

Watch your symptoms closely, and take note of the timing as much as you can. How long do symptoms last? What makes them worse/less? How do they relate in time to headache (if any – remember, it is possible to have migraine with no headache at all)? How often do you experience these symptoms?

What has been your experience with treatment and diagnosis? Your comments below will help us all learn.