A new study from the Netherlands provides evidence that vestibular function tests, particularly the video head impulse test (vHIT) and caloric testing, can support clinicians in distinguishing between Menière’s disease (MD) and vestibular migraine (VM)—two vestibular conditions that frequently present with overlapping symptoms.
The research, conducted at the Apeldoorn Dizziness Centre and published in Frontiers in Neurology, analyzed 668 patients diagnosed with MD and/or VM using updated diagnostic criteria endorsed by the Bárány Society. The investigators found that certain vestibular test patterns were more common in MD than in VM and proposed an optimal threshold to improve diagnostic accuracy.
Significant Symptom Overlap Complicates Diagnosis
Menière’s disease is a chronic condition characterized by recurrent episodes of vertigo, hearing loss, tinnitus, and aural fullness. Vestibular migraine, on the other hand, involves vertigo episodes linked to migraine symptoms such as headache, photophobia, and aura. Despite their differing pathophysiologies, the two conditions often resemble one another in early stages, making accurate diagnosis challenging.
According to the researchers, “more than half of our clinically diagnosed VM patients also experienced subjective hearing loss, tinnitus, or aural fullness, symptoms which are usually assigned to MD.” In their sample, 65.7% of VM patients reported at least one aural symptom during vertigo episodes, while these symptoms were present in 100% of MD patients.
Moreover, audiometric testing revealed that while MD patients typically showed pronounced and asymmetrical low-frequency hearing loss, a subset of VM patients (24.2%) also exhibited measurable hearing loss, albeit less severe and not consistent with the MD pattern.
Demographic differences were also noted: 86.1% of the VM group were female, compared to 46.4% in the MD group. This aligns with broader epidemiological trends showing a higher prevalence of migraine in women.
Caloric and vHIT Testing Offer Diagnostic Value
The study evaluated the diagnostic performance of two common vestibular assessments: caloric testing, which measures low-frequency vestibular function via thermal stimulation, and the vHIT, which assesses high-frequency vestibulo-ocular reflex (VOR) responses during head impulses.
Abnormal caloric test results were observed in 66.3% of MD patients and in 28.0% of VM patients. The median unilateral weakness (UW) in MD patients was significantly higher (48.0%) than in VM patients (33.0%). A dissociation between vHIT and caloric test results—defined as a normal vHIT with an abnormal caloric test—was seen in 56.5% of MD cases, compared to 24.2% in VM.
The vHIT alone had a positive predictive value (PPV) of 81% for MD, while the negative predictive value (NPV) was lower at 36%. In patients with a normal vHIT, performing the caloric test improved diagnostic performance: the caloric test in this subgroup yielded a PPV of 82% and an NPV of 55%.
Using receiver operating characteristic (ROC) analysis, the researchers determined that increasing the threshold for abnormal UW from 22% to 34% improved diagnostic accuracy. At this threshold, the caloric test showed a PPV of 90% and an NPV of 52% for identifying MD over VM.
“An abnormal vHIT or caloric test result is not specific for a diagnosis of MD, but such findings make a diagnosis of MD more likely than VM,” the authors wrote.
Implications for Clinical Decision-Making
While patient history and audiometric findings remain the foundation for diagnosis, the addition of vestibular testing appears to enhance diagnostic confidence, particularly in ambiguous cases. The authors emphasized that these tests may be most useful for patients who do not fully meet diagnostic criteria for either MD or VM.
“Based on our results, the vHIT and caloric test may be helpful in patients in whom there is diagnostic uncertainty between MD and VM,” the researchers noted. They propose that in patients with clear vestibular loss and recurrent vertigo, an abnormal vHIT alone may be sufficient to support an MD diagnosis, making additional caloric testing unnecessary.
The study also highlighted the value of updated diagnostic frameworks and larger sample sizes in refining clinical understanding. Unlike previous investigations, which often lacked rigorous classification or included small cohorts, this study applied the latest international diagnostic criteria and included nearly 200 patients with confirmed unilateral MD and over 100 with confirmed VM.
However, the researchers caution that their findings are limited to a tertiary care population and may not generalize to all patients presenting with dizziness. Additionally, the diagnostic performance measures are specific to populations consisting solely of MD and VM patients and should not be applied directly to broader differential diagnoses.
Despite these limitations, the authors conclude that “vestibular function tests may support diagnostic refinement and treatment planning in patients who do not (yet) completely fulfill the criteria for VM nor for MD.” Their data suggest that a unilateral caloric weakness of 34% or greater, particularly when vHIT is normal, should raise clinical suspicion for MD.
Reference:
- Vosbeek, E. G. M., Seelen, M., Vingerhoed, A. M., Schermer, T. R., Cannegieter, S. C., Terwindt, G. M., & Bruintjes, T. D. (2025). Vestibular function tests are helpful in differentiating between Menière’s disease and vestibular migraine. Frontiers in Neurology. https://doi.org/10.3389/fneur.2025.1569247
