Vestibular Migraine – Part II

The symptoms of vestibular migraine are so varied that the list below represents only a small sample of related complaints that I have heard from suspected Migraineurs:

“I have episodes of spinning and nausea that come on without warning, but had no ear symptoms.”
“It felt like someone suddenly pulled the rug out from under me.”
“I felt a sudden wave come over me.”
“I can’t stand any type of motion. It never bothered me when I was a kid.”
“I just feel kind of “spaced out” a few days a month.”
“ I get sick just watching traffic go by”

As a vestibular practitioner, you need to ask some questions about related issues that may not be apparent (or not apparently related) to the patient. For example, do the episodes seem to occur on a regular monthly basis? (Migraine is more common in women, and symptoms tend to be worse around the menstrual cycle.) Have they ever had classic migraines with headache and sensitivity to light and sound? (Migraine symptoms can change over time, particularly after a hormonal event like pregnancy, childbirth or menopause.) Do they have any fullness or tinnitus in one ear at the time of an episode of vertigo? (Generally, episodic vertigo of migraine etiology is not accompanied by any auditory symptoms, so complaints of unilateral tinnitus or aural fullness would be inconsistent with migraine). Is there a family history of migraine? (There is a higher likelihood of migraine when one or both parents have a history of migraine type headaches.)

The diagnosis of vestibular migraine (as well as classic migraine) is accomplished largely by clinical history, negative examinations for other causes of vestibular symptoms, and a positive response to migraine treatment. Unfortunately, it is not that simple because many patients with vestibular migraine have abnormal vestibular function tests.

Cass et al (1997) use the following criteria for establishing a diagnosis of vestibular migraine:

1. History of migraine headaches
2. Family history of migraine
3. History of space and motion intolerance
4. Vestibular symptoms that do not fit other common vestibular disorders.

These patients require a comprehensive vestibular evaluation. Some vestibular specialists note certain patterns on vestibular tests that they feel are consistent with vestibular migraine. These include:

1. Hyperactive caloric response (either unusually high SPV or a strong vegetative response)
2. Increased gain on Visual/Vestibular Interaction tests
3. Long time constants on Step Velocity tests.

Vestibular evaluation may identify or effectively rule out labyrinthine dysfunction. A neurologist familiar with the characteristics and treatment of vestibular migraine may be consulted.

About Alan Desmond

Dr. Alan Desmond is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. In 2015, he received the Presidents Award from the American Academy of Audiology.