Vestibular disorders are amongst the most common causes for dizziness accounting for around 40% of all dizziness. In recent years it has become apparent that vestibular migraine is one of the most common vestibular disorders and may even be the most common cause of recurrent episodic spontaneous vertigo.
There is not a diagnostic test for vestibular migraine and the diagnosis is made based on the symptom presentation. That is not to say that diagnostic measures are not useful in the assessment of migraineurs. Most individuals with peripheral (ear related) vestibular disorders have abnormal vestibular and/or hearing examinations. Central (brain) vestibular disorders typically have normal vestibular function and hearing tests, as such these assessments can also help with diagnosis.
The Barany Society has recommended criteria for making the diagnosis of vestibular migraine that can be found below. Frequently it is difficult to distinguish vestibular migraine from other vestibular disorders due to symptom overlap. It is often most difficult to separate vestibular migraine from Meniere’s disease due to the significant overlap in symptoms that can occur.
The Barany Society criteria for the diagnosis of Meniere’s disease can also be found below. The pathophysiology of Meniere’s disease is poorly understood with a multitude of possible theories as the cause of the condition. The pathophysiology of migraine is also not fully understood.
Interestingly, many individuals that have Meniere’s disease also have a history of migraine.
Vestibular Migraine Diagnosis
Vestibular symptoms that frequently occur with vestibular migraine
- Rotary vertigo that is often triggered by physical or visual motion, stress, busy visual environments, and poor sleep.
- It is also common to hear symptoms of vertigo described more as a rocking or swaying sensation instead of a spinning type of vertigo.
- Motion sickness or motion intolerance
Auditory symptoms that may occur with migraine
- Tinnitus
- Aural fullness
- Ear pain
- Sound sensitivity
**A more detailed review of the vestibular and auditory manifestations of migraine can be found here.
Criteria for Vestibular Migraine from the Barany Society
Vestibular migraine
- At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours.
- Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD).
- One or more migraine features with at least 50% of the vestibular episodes: – headache with at least two of the following characteristics: one sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity, photophobia and phonophobia, visual aura.
- Not better accounted for by another vestibular or ICHD diagnosis.
Probable vestibular migraine
- At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours.
- Only one of the criteria B and C for vestibular migraine is fulfilled. (migraine history or migraine features during the episode)
- Not better accounted for by another vestibular or ICHD diagnosis.
Criteria for Meniere’s Disease (MD) from the Barany Society
Definite MD
- Two or more spontaneous episodes of vertigo, each lasting 20 minutes to 12 hours.
- Audiometrically documented low- to medium frequency sensorineural hearing loss in one ear, defining the affected ear on at least one occasion before, during or after one of the episodes of vertigo.
- Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the affected ear.
- Not better accounted for by another vestibular diagnosis.
Probable MD
- Two or more episodes of vertigo or dizziness, each lasting 20 minutes to 24 hours.
- Fluctuating aural symptoms (hearing, tinnitus, or fullness) in the affected ear.
- Not better accounted for by another vestibular diagnosis.
Other tips in distinguishing Meniere’s disease from migraine
We take a thorough case history in an attempt to determine the most likely diagnosis. In some cases, particularly cases of Meniere’s disease versus vestibular migraine, there can be such significant symptom overlap that the cause cannot be determined by case history alone. In cases such as this, we have some recommendations to help clarify the likely source of the symptoms.
We recommend stat hearing tests if there are any perceived hearing changes as well as ongoing monitoring of hearing. With repeated episodes, Meniere’s disease will often cause some degree of sensorineural hearing loss, often impacting the low frequencies first. If possible, documenting fluctuating sensorineural hearing loss can also support a diagnosis of Meniere’s disease.
Symptoms of tinnitus, aural fullness, and otalgia can be worked up with a hearing test, tympanometry, physical assessment by otolaryngology, and imaging in some cases, to rule in/out ear related causes for the symptoms.
We have patients utilize their smart phones to record their eyes during episodes of vertigo. If someone is experiencing an episode of vertigo from Meniere’s disease there will most often be a robust horizontal nystagmus, while it is rare for vestibular migraine to cause an intense nystagmus pattern such as this.
We look for vestibular function test patterns to help support diagnosis. Frequently individuals with Meniere’s disease exhibit a pattern of normal vHIT and abnormal caloric irrigation, while most cases of vestibular migraine have both normal vHIT and caloric irrigation.
We often request that patients pay close attention to associated symptoms and triggers for the episodes, which can often help direct diagnosis. The majority of patient’s do not know this is something that is important to pay attention to unless you tell them. For instance, it would be unusual for someone to have an episode of Meniere’s disease triggered by a change in barometric pressure while this is a common trigger for episodes of migraine. Additionally, migraines are commonly triggered by hormonal fluctuation such as menses or menopause, while these are less likely to trigger Meniere’s symptoms.
Often individuals with vestibular migraine will have a personal or family history of migraine, as well as motion intolerance/motion sickness. One should inquire about this in the case history.
Most individuals with Meniere’s disease are not bothered by vestibular function tests such as caloric irrigation, while most migraineurs find vestibular testing symptom provoking. The patient’s subjective response to vestibular function tests can also be weighed in when attempting to separate these two diagnoses.
Age at symptom onset can give some clues as to the statistically more likely diagnosis. In most cases vestibular migraine impacts people in early to middle adulthood while Meniere’s disease typically presents at a later age. Both vestibular migraine and Meniere’s disease are more likely to impact females than males.
Summary
It is important to be aware of the multitude of dizziness and ear related symptoms that migraine can cause and the difficultly this can create in localizing the symptom cause. Individuals with dizziness and/or otologic type symptoms will often undergo hearing and/or vestibular examinations to help better localize where their symptoms are coming from.
Typically, migraine is managed by a neurologist with a combination of treatments that could include: lifestyle modifications such as eating a healthy diet, avoiding common dietary triggers for migraine, supplements, and with medications that are either prophylactic or abortive.
Typically, Meniere’s disease is managed by an otolaryngologist with a treatment ladder that may consist of the following: low sodium diet, diuretic, histamine agonists such as betahistine, intratympanic steroid injections, or even ablative procedures such as gentamicin injection.
We know that either of these conditions, if not properly treated, can lead to more chronic symptoms. The treatments are quite different for these two conditions and as such correct diagnosis is essential for symptom improvement.
