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Is dizziness a sign of migraine?

“ ...I think ‘twas that shaggy black creature from Hell that cannot bear me in his kingdom on Earth ...” – Martin Luther commenting on his recurring dizzy spells. From today’s perspective, Luther’s shaggy dog was probably a condition first described in the medical literature by Prosper Ménière in 1862.

In this very first description of the inner ear disorder that bears his name, Ménière noted that many people with the condition were migraineurs. Vertigo (spinning dizziness) in migraine has only recently gained traction as a research topic. The science on migraine-related vertigo is unclear. One study found that only 10% of people are diagnosed correctly.

Recent research shows that migraine is more common in people with Ménière’s disease than healthy control subjects. Migraine and Ménière’s disease may be inherited together as a symptom cluster.

Vestibular migraine

Vertigo can occur independently of Méniere's disease in association with a migraine disorder. This condition is called vestibular migraine. The International Classification of Headache Disorders features vestibular migraine in section A1.6.6. These vertigo events (note: they are not aura) may occur years after the first headache symptom and differ from Méniere's disease by the absence of progressive hearing loss. Based on the diagnostic criteria, it was found that approximately 1% of the population is affected by vestibular migraine.

People with the condition report similar triggers for headache and vertigo. The vertigo may occur without an accompanying headache. Sitting up, lying down, looking up, bending down can all make the dizzy sensation worse. Vertigo may be rotational (like getting off a roundabout), swaying (like being on board a ship) or make you unsteady on your feet. Some people report feeling "drunk," "seasick," or like they just got off a roller coaster. About one-third of people say the symptoms last a few minutes. About another third say they last for hours or days. The remaining 10% have constant vertigo of fluctuating severity.

Although there is no one specific test that proves vestibular migraine beyond a doubt, you will still need to see a neurologist and an ear, nose and throat specialist for tests to rule out other diseases, some of which may be serious. Useful procedures include a video head impulse test and speech discrimination testing. These tests can help to distinguish the condition from Ménière's disease. Ultimately, vestibular migraine remains a condition that is diagnosed largely on the basis of your medical history.

The vertigo associated with vestibular migraine probably has the same underlying mechanism as the headache. The science is homing in on the trigeminovascular system. The trigeminal nerve is a cranial nerve believed to be one of the factors involved in migraine. It is also the nerve serving the blood vessels of the vestibular system (the organ of balance inside the inner ear). The pain processing regions of the brainstem are known to be associated with the vestibular system and also with the trigeminovascular system. This is why experts believe that an interaction of different brain regions with each other is involved in causing vertigo in vestibular migraine.

Vertigo may also be caused by another form of migraine disorder, but in those cases there would be additional symptoms such as speech disorders.

 

International Headache Society diagnostic criteria for vestibular migraine:

  1. At least five episodes fulfilling criteria C and D
  2. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura
  3. Vestibular symptoms of moderate or severe intensity lasting between 5 minutes and 72 hours
  4. At least half of episodes are associated with at least one of the following three migrainous features
  5. Headache with at least two of the following four characteristics:
  6. a) unilateral location
  7. b) pulsating quality
  8. c) moderate or severe intensity
  9. d) aggravation by routine physical activity
  10. Photophobia and phonophobia
  11. Visual aura
  12. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.

 

  • 1. Huang TC, Wang SJ, Kheradmand A. Vestibular migraine: An update on current understanding and future directions. Cephalalgia. 2019 Aug 8:333102419869317. doi: 10.1177/0333102419869317.

    2. Headache Classification Committee of the International Headache Society (IHS) The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018 Jan;38(1):1-211. doi: 10.1177/0333102417738202.

    3. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, Bisdorff A, Versino M, Evers S, Newman-Toker D. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-72. doi: 10.3233/VES-2012-0453.

    4. Furman JM, Marcus DA, Balaban CD. Vestibular migraine: clinical aspects and pathophysiology. Lancet Neurol. 2013 Jul;12(7):706-15. doi: 10.1016/S1474-4422(13)70107-8. Review.

    5. Neff BA, Staab JP, Eggers SD, Carlson ML, Schmitt WR, Van Abel KM, Worthington DK, Beatty CW, Driscoll CL, Shepard NT. Auditory and vestibular symptoms and chronic subjective dizziness in patients with Ménière's disease, vestibular migraine, and Ménière's disease with concomitant vestibular migraine. Otol Neurotol. 2012 Sep;33(7):1235-44. doi: 10.1097/MAO.0b013e31825d644a.

    6. Formeister EJ, Rizk HG, Kohn MA, Sharon JD. The Epidemiology of Vestibular Migraine: A Population-based Survey Study. Otol Neurotol. 2018 Sep;39(8):1037-1044. doi: 10.1097/MAO.0000000000001900.

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