Vestibular migraines (VM) are a neurological condition characterized by episodes of vertigo and dizziness, often accompanied by migraine symptoms. This blog post provides an overview of the diagnosis criteria, underlying physiology and pathology, risk factors, and available treatment options for VM, supported by research references.
Disclaimer
This information is for educational purposes only and is not intended as medical advice. Please consult your doctor or healthcare provider for a proper diagnosis and treatment plan tailored to your specific condition.
Diagnosis Criteria for Vestibular Migraine
Vestibular migraines are diagnosed based on criteria from the International Classification of Headache Disorders (ICHD-3):
- At least five episodes fulfilling the following conditions:
- Moderate to severe vestibular symptoms lasting 5 minutes to 72 hours.
- Migraine history or features during attacks, including:
- Headache with at least two of these characteristics: unilateral location, pulsating quality, moderate to severe pain, or worsening by physical activity.
- Photophobia and phonophobia.
- Visual aura.
- Not attributed to another vestibular or neurologic disorder.
Vestibular Symptoms: These include spontaneous vertigo, positional vertigo, head motion-induced dizziness, and visually induced vertigo.
Physiology and Pathology of Vestibular Migraines
The exact mechanisms underlying vestibular migraines remain unclear, but several theories exist:
- Central Sensitization:
- Increased sensitivity in the brainstem and cortex to vestibular and sensory inputs contributes to dizziness and vertigo.
- Neurovascular Dysfunction:
- Abnormal activity in the trigeminovascular system leads to cortical spreading depression (CSD) and blood flow changes affecting the vestibular pathways.
- Vestibular Pathway Involvement:
- Dysfunction in areas like the vestibular nuclei, cerebellum, and thalamus affects vestibular processing.
- Genetic Predisposition:
- Family studies suggest a genetic component, with overlaps in migraine and vestibular system dysfunction.
Risk Factors for Vestibular Migraines
- Migraine History:
Individuals with a personal or family history of migraines are at higher risk. - Hormonal Influences:
- Women are disproportionately affected, likely due to hormonal fluctuations.
- Vestibular migraines often correlate with menstruation, pregnancy, or menopause.
- Triggers:
Common triggers include stress, sleep disturbances, certain foods (e.g., caffeine, chocolate), alcohol, weather changes, and sensory overstimulation. - Comorbid Conditions:
Anxiety disorders, motion sickness, and other vestibular conditions like Meniere’s disease are associated with higher risk.
Treatment Options for Vestibular Migraines
1. Lifestyle Modifications
- Maintain a consistent sleep schedule.
- Manage stress with relaxation techniques, yoga, or meditation.
- Avoid common dietary triggers.
- Engage in regular, moderate exercise.
2. Acute Management
- Vestibular suppressants: Medications like meclizine or dimenhydrinate can relieve vertigo during attacks.
- Triptans: Effective for acute migraine symptoms if taken early.
3. Preventive Medications
- Antihypertensives: Propranolol, verapamil.
- Anticonvulsants: Topiramate, valproate.
- Antidepressants: Amitriptyline, venlafaxine.
- CGRP Monoclonal Antibodies: Newer migraine treatments showing promise for VM prevention.
4. Vestibular Rehabilitation Therapy (VRT)
- Customized exercises to improve balance and reduce sensitivity to motion and visual stimuli.
5. Non-Pharmacological Therapies
- Biofeedback and Cognitive Behavioral Therapy (CBT): Helpful in managing stress and anxiety, which can exacerbate symptoms.
- Acupuncture: Some evidence supports its use in migraine management.
6. Emerging Treatments
- Neuromodulation Devices: Transcranial magnetic stimulation and vagus nerve stimulators show potential.
- Dietary Supplements: Magnesium, riboflavin, and CoQ10 have shown benefits in migraine prevention.
References
- Lempert T, Olesen J, Furman J, et al. “Vestibular migraine: Diagnostic criteria.” Cephalalgia. 2012.
- Edlow JA, Newman-Toker DE. “A new diagnostic approach to dizziness in acute care.” BMJ. 2016.
- Bisdorff AR. “Management of vestibular migraine.” Therapeutic Advances in Neurological Disorders. 2020.
- American Migraine Foundation. “Vestibular Migraine.” 2021.
- Headache Classification Committee of the International Headache Society (IHS). “The International Classification of Headache Disorders, 3rd edition.” Cephalalgia. 2018.
- Furman JM, Balaban CD, Jacob RG, et al. “Migraine-anxiety-related dizziness.” Annals of Otology, Rhinology & Laryngology. 2005.
What I Recommend to My Patients with Vestibular Migraines
When managing vestibular migraines, my approach is rooted in empowering patients to understand their unique triggers and develop strategies to manage symptoms effectively. Here are some of the initial steps and resources I often recommend:
1. Start a Symptom and Trigger Journal
Understanding your personal triggers is essential to managing vestibular migraines. Keeping a journal helps identify patterns and possible “trigger stacking”—when multiple smaller triggers combine to lower your migraine threshold.
What to Track in Your Journal:
- Daily activities and stress levels.
- Foods and beverages consumed.
- Sleep patterns.
- Environmental factors (e.g., weather changes, bright lights).
- Symptoms (severity, duration, and type).
This awareness is the foundation for avoiding or mitigating triggers over time.
2. Understand Trigger Stacking
“Trigger stacking” occurs when multiple small triggers combine to bring on a migraine episode. For example:
- If you’re slightly dehydrated, sleep-deprived, and exposed to bright lights, the cumulative effect can lower your threshold for symptoms.
By identifying and managing these smaller triggers, you can raise your migraine threshold and improve symptom management.
3. Grounding Exercises and Nervous System Regulation
Many patients benefit from tools that calm the nervous system and reduce sensitivity to triggers. These techniques can help your body remain in a more regulated state, even during challenging situations.
Suggestions Include:
- Breathing Exercises: Diaphragmatic breathing or box breathing.
- Progressive Muscle Relaxation: A method to reduce tension in the body.
- Mindfulness Practices: Meditation or guided imagery to help lower stress levels.
- Gentle Movement: Restorative yoga, tai chi, or vestibular-specific exercises.
Regulating your nervous system can not only reduce symptoms but also help increase resilience to future triggers.
4. People to Follow on Instagram
I recommend following these experts for accessible tips, recipes, and community support:
- The Migraine Dietitian (@migrainedietitian): Offers evidence-based dietary guidance for managing migraine triggers.
- The Dizzy Cook (@thedizzycook): Shares recipes and lifestyle tips tailored for vestibular conditions and migraines.
- Dr. Emily Kostelnik (@dremilykostelnik): A vestibular physical therapist who provides valuable education on managing dizziness and vestibular disorders.
These accounts are great resources for practical strategies and support from professionals who understand vestibular migraines.
5. Personalized Guidance
Every patient’s journey with vestibular migraines is unique. While these general strategies can be a helpful starting point, personalized care is key. Whether it’s refining your exercise routine, adjusting your diet, or exploring therapies, I’m here to help guide you through your options.
If you’re interested in learning more or scheduling a consultation, contact me at Strength & Balance Physical Therapy. Together, we can create a plan to help you regain control and thrive.
Disclaimer:
This information is not medical advice and is for educational purposes only. Please consult your doctor or healthcare provider for diagnosis and a treatment plan tailored to your needs.
McKenzie DiStefano PT/DPT
Vestibular Healing Insights 
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