Vestibular Migraine: When Migraine Causes Dizziness Instead of Headache

Vestibular migraine (VM) is currently the most common cause of recurrent spontaneous vertigo in adults — yet it remains largely undiagnosed because the dizziness occurs without headache in approximately 30% of episodes, leading patients to seek care from ENT rather than neurology, and to be misdiagnosed with Menière's disease, BPPV, or "labyrinthitis." VM is a migraine variant where the brain's migraine process activates the vestibular system, producing vertigo as the dominant symptom.

Diagnostic Criteria

According to the International Classification of Headache Disorders (ICHD-3): at least 5 episodes of vestibular symptoms of moderate or severe intensity; a current or past history of migraine (with or without aura); at least 50% of VM episodes associated with at least one of: headache, photophobia, phonophobia, or visual aura; episodes lasting 5 minutes to 72 hours; no better explanation from another diagnosis.

Clinical Features

Episodes: spontaneous vertigo (room spinning without positional trigger), positional vertigo (mimicking BPPV), or head-motion-induced dizziness. Duration varies enormously — from minutes to days. Associated features during or around the episode: photophobia and phonophobia; visual aura (flickering lights, zigzag lines); headache (often mild — overshadowed by the vertigo); increased sensitivity to motion. Common triggers: the same triggers as migraine — sleep disruption, stress, menstruation, certain foods, bright lights, and weather changes.

How to Distinguish from Menière's Disease

Menière's: hearing loss (low frequency, fluctuating), ear fullness, and tinnitus in the same ear as the vertigo. VM: typically no hearing involvement; positive migraine history; visual sensitivity during attacks. A detailed history of migraine features and triggers is the key. Treatment of VM: acute attacks with vestibular suppressants (cinnarizine, ondansetron); prevention with standard migraine preventives — propranolol, amitriptyline, topiramate, or the CGRP antibodies. Sri Anand CNC, Chanda Nagar, Hyderabad. Call +91 90633 66983.