FFS: Vestibular migraine

Essentially, vestibular migraine is said to be a migraine headache that induces vertigo—presumably due to vasospasm of blood vessels in regions of the brainstem responsible for balance.

It is an emerging popular diagnosis for patients with unexplained recurrent vertigo and, along with Meniere’s disease, is thought to be one of the most common causes of recurrent spontaneous vertigo.

However, there is significant controversy and diversity of opinion regarding the nature of this condition. Some experts have questioned the validity of the term, suggesting it may be a “marriage of convenience” of migraine and vertigo, especially given the vague definitions and lack of objective diagnostic criteria.

Some proponents note that up to 50% of patients may present without headache.

Regardless, emergency department (ED) assessment focuses on ruling out more sinister causes of acute vertigo and headache, rather than making a definitive diagnosis of vestibular migraine.

The diagnosis is ultimately clinical and best made by a neurologist. A good response of vertigo to triptans supports a migrainous aetiology.

Pathology

Vestibular migraine is characterised by vertigo accompanying a migraine attack. The likely mechanism is vasospasm affecting brainstem areas involved in balance and vestibular processing.

Clinical features

The spectrum of clinical features is broad and variable, even within the same patient over time.

Typical features include:

• Recurrent episodes of spontaneous vertigo without hearing loss or tinnitus
• Vertigo occurring before, during, or between headaches
• Associated migraine symptoms such as photophobia or aura
• Positional or chronic fluctuating vertigo
• Motion sensitivity
• Normal neurological examination, including coordination and gait

Formal diagnostic criteria include:

1. Recurrent episodes of unexplained vertigo
2. A formal migraine diagnosis based on IHS criteria
3. Migraine symptoms during attacks (e.g. headache, photophobia, aura)
4. Exclusion of other causes

A diagnosis of probable vestibular migraine may be used when features are suggestive but not fully diagnostic.

Investigations

The primary aim is to rule out alternative diagnoses.

Blood tests (to rule out differentials or complications from vomiting):

• FBC
• CRP
• U&Es/glucose

Imaging:

• CT brain/CT angiogram if there is suspicion of alternative serious diagnoses
• MRI/MRA brain is the best modality to exclude other central causes of headache/vertigo

Management

Preventative treatment:

• Migraine prophylactic medications may reduce the frequency/severity of episodes
• Consider empirical prophylaxis in cases of unexplained recurrent vertigo without auditory symptoms

Acute treatment:

• Anti-emetics such as prochlorperazine
• Triptans may be effective for acute vestibular migraine

Disposition

Vestibular migraine is difficult to diagnose on first presentation. Specialist neurological assessment should be sought before a firm diagnosis is made.

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References

Publications

• Nelson JA, Viirre E. The clinical differentiation of cerebellar infarction from common vertigo syndromes. West J Emerg Med. 2009 Nov;10(4):273-7
• Phillips J, Longridge N, Mallinson A, Robinson G. Migraine and vertigo: a marriage of convenience? Headache. 2010 Sep;50(8):1362-5. 
• Vestibular Migraine. Royal Victorian Eye and Ear Hospital

FOAMed

• Coni R. Migraine Headache. LITFL
• Hayes J. FFS: Migraine Headache. LITFL