Vestibular Migraine 101 (Migraine-Associated Vertigo)

Do you recognize these symptoms?

People describe Vestibular Migraine (VM) as:

• “I feel like I am veering to one side when I get these headaches.”
• “I feel dizzy and nauseous and am sensitive to light and sounds.”
• “Even when I don’t get a headache, the dizziness, sensitivity to light, and nausea are incapacitating.”
• “I get a pounding headache on the right side of my head and feel like I’m walking across a rocking boat.”
• “I get a pain in my neck and feel pressure in my head. I feel like I can’t walk straight”
• “I will get a sick headache and it hurts to move. When I move my head I feel like I have physically moved”
• “Sometimes I will be dizzy for a moment. Sometimes the dizziness seems to go on for the better part of a day. I don’t even always get a headache.”
• “I get zigzagging lines before my eyes and feel lightheaded. Sometimes I will get a pounding headache on the side of my head after my vision returns to normal. Sometimes I can’t walk straight.”

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Small moving lines or flashing spots, first noticed in the center or the line of sight, are for many Vestibular Migraine (VM) sufferers the initial sign informing them that they are about to experience a migraine.

These geometric intrusions in your sight can not be blinked away or made to stop by simply closing your eyes.

People who experience these auras will see moving flashing light images disturbing the darkness when they close their eyes. Eyes opened or closed, the sufferer will notice that the shapes stretch and move toward the periphery of sight before disappearing.

The amount of time a VM sufferer may experience a visual aura can vary from migraine to migraine. Even those who frequently experience a visual aura may experience a migraine without an accompanying aura.

It is also possible for a Vestibular Migraine sufferer to experience a visual aura that isn’t followed by a painful headache.

These visual auras may be accompanied by tingling in the hands, feet, and facial features on occasion for some Vestibular Migraine sufferers.

After the visual aura subsides, the migraine sufferer may experience a throbbing headache on one side of the head. This pain may be intense or more subtle. The amount of pain any individual migraine sufferer may differ with each experience of the headache.

Feelings of dizziness, disproportionate movement, motion sickness, or vertigo accompany the headache pain for those experiencing Vestibular Migraine.

The individual may also experience an increased sensitivity to light, sound, and smells. All of this may be accompanied by nausea and/or vomiting.

People who experience Vestibular Migraines (VM) can have any, or all, of the symptoms of migraine headaches accompanied by feelings of unsteadiness, dizziness, being off balance, or feeling like they are experiencing motion sickness.

Many people indicate that moving their head or eyes can lead to a sense of dizziness. Some sufferers feel like they are unable to walk in a straight line. Some people will feel like they have moved great distances when taking a small step. Others will experience the sensation of falling when they attempt to lift or move their head even the slightest amount.

People with VM may sometimes experience headaches without the dizziness or dizziness without the accompanying headache.

Although many people don't notice symptoms prior to their visual disturbance, some migraine sufferers will remember struggling with words or being unusually uncoordinated or clumsy prior to experiencing a visual aura or, the individual doesn’t experience an aura, the onset of a migraine. The amount of time that passes between the ending of a visual aura and the onset of the pounding headache may vary from person to person and from migraine to migraine.

The ICHD-III (international classification of headache disorders) identifies the symptoms of Vestibular Migrane as:

• Head motion induced vertigo which is caused by moving the head.
• Head motion induced dizziness with nausea which refers to dizziness that feels like spatial disorientation.
• Positional vertigo which occurs after a change in the position of the head.
• Spontaneous vertigo which can be associated with the feeling that your body is moving (referred to as internal vertigo) or with the feeling that the environment around you is spinning or flowing (referred to as external vertigo).

Overlapping Symptoms of Headache Diagnoses

If you look at the symptoms provided above with a level of confusion, you aren’t alone.

Many people who struggle with migraine headaches, and doctors who work with individuals suffering from headaches, find it difficult to clearly distinguish one type of headache from another.

Add to the similarity of different headache syndromes the fact that many migraine sufferers will have different experiences with their headaches from time to time, and you can easily understand how complex and confusing it can be to determine exactly what type of headache you are suffering with.

Many migraine sufferers will experience a visual aura from time to time, but few experience an aura with each migraine.

Many people who experience a visual aura will have a lag between the aura and the onset of the migraine. The amount of time that occurs between the ending of visual disturbances and the onset of a headache can vary from moments to hours.

Likewise, many people who suffer from migraine headaches will experience bouts of sensitivity to light, sound, and smells. However, an individual will often not experience these symptoms with each headache and will often experience these symptoms to a different level from one episode to another. Many migraine sufferers will experience a visual aura and/or bouts of dizziness or vertigo without an accompanying headache.

Clearly, this adds to the confusion surrounding diagnosis of migraines.

Overlapping Symptoms of Migraines and Vestibular Diagnoses

Dizziness is one of the most common symptoms that lead individuals to seek medical care.

About 40% of individuals that experience migraine headaches have some accompanying vestibular syndrome at onetime or another.

For some people, these vestibular symptoms accompany their migraine episodes. For others, the experience of dizziness, vertigo, and/or motion sickness may be totally independent of their experience with migraines.

Vestibular symptoms that frequently correlate with migraine headaches include

• motion sickness associated with eye, head, and/or body movement, dizziness, attacks of vertigo (frequently associated with nausea and/or vomiting),
• heightened sensitivity to light accompanied by an increased difficulty focusing one’s vision,
• increased sensitivity to sound accompanied by tinnitus,
• neck pain with muscle spasms in upper cervical spine musculature,
• loss of balance and ataxia,
• increased confusion and alterations to normal cognitive function,
• anxiety and panic,
• and, spatial disorientation.

Migraine headaches are often associated with recurrent benign vertigo in adults and benign paroxysmal vertigo of childhood (BPVC which is experienced as sudden episodes of dizziness that lasts a few seconds to a minute).

Some individuals suffering from migraine headaches present with benign paroxysmal positional vertigo (BPPV). They may experience a sudden mild to intense sensation of spinning accompanied by a loss of balance and nausea and/or vomiting lasting up to a minute.

Nystagmus (abnormal rhythmic eye movements) may also accompany these symptoms.

Many events and foods that trigger vestibular episodes are also known to act as triggers for migraine headaches.

Such triggers include hormone fluctuations, changes in barometric pressure, and foods that are smoked, fried, or fermented. Other foods associated strongly with instances of vestibular symptoms and migraines include chocolate, red wine, aged cheeses, onions, and foods prepared with MSG.

About Vestibular Migraine Headaches

Vestibular Migraine (VM) is a migraine attack that occurs with dizziness, a sense of imbalance, or vertigo. Vestibular Migraines may also be referred to as Migrainous Vertigo, Migraine-Associated Vertigo, or Migraine-Related Vestibulopathy.

People who suffer with Vestibular Migraines (VM) may sometimes experience other symptoms without the headache. Even in this configuration the episode can be very debilitating.

“Vestibular” refers to the inner ear and Vestibular symptoms may vary greatly from person to person. Some people with VM may experience a spinning sensation. Others may have a sensation of moving out of proportion to the environment. They may feel that they are lurching when taking a small step, or they feel that they are falling when moving their head slightly.

There are no blood tests or imaging tests that can provide a definitive diagnosis of VM.

Doctors have a limited understanding of what causes these migraines. It is generally understood that VM is caused by misfiring of nerve cells in the brain.

The vertigo symptoms associated with VM tent to strike suffers around the age of 40.

You may be suffering from VM if:

• You have migraines or have a history of migraines.  
• You have experienced at least five episodes of vertigo. These episodes may make you feel like you are moving or spinning.
• The feelings of vertigo last anywhere from a few minutes to three days.
• If these feelings are sufficient to keep you from doing things you would ordinarily do. (You should note that these feelings may be much more severe than described above and may make it impossible for you to get anything done.)

At least half of the times that you experience these symptoms you also experience:

• A headache characterized by two or more of these. The headache gets worse with activity. The headache occurs on one side of your head. The headache throbs or pounds. The headache is moderate to severe in nature (Note: a moderate headache will keep you from doing things that you would ordinarily do).
• You experience sensitivity to light or sounds.  
• You experience a migraine aura. A migraine aura occurs when you see shimmering or flashing lights.

About Causes

Doctors aren’t sure exactly what causes Vestibular Migraine (VM) Headaches. Although there are several theories about what causes VM Headaches, the exact mechanism of what occurs is not completely understood. It is generally understood that VM Headaches are caused by misfiring of cells in the brain.

There is some belief that there are interactions between pain and balance pathways in the brain when a person suffers a VM attack.

It is also believed that there may be abnormalities in the inner ear of VM sufferers that cause the balance issues.

According to Dr. Jason D. Rosenberg at Johns Hopkins Headache Center, vertigo may be “another part of migraine hypersensitivity like pain and photophobia.”

Common Triggers for Vestibular Migraines?

Like most migraine headaches, people who suffer from VM often control their attacks by learning and avoiding their particular triggers.

Some common triggers include:

• Stress
• Anxiety
• Certain foods: caffeine, some dairy products (aged cheeses, sour cream, yogurt), chocolate, onions, olives, pickles, smoked or cured meats, foods containing monosodium glutamate (MSG),alcohol
• Getting too much sleep
• Not getting enough sleep
• Environmental factors like bright or flashing lights or changes in barometric pressure
• Hormonal changes

Facts About Vestibular Migraine Headache

Approximately 25% of those who suffer with VM Headaches will experience temporary visual disturbances. These disturbances may appear as:

• Zig zagging patterns. These patterns may appear as colored or black and white images
• Small bright or flickering dots
• Loss of vision
• Visual static or snow
• Blurry Vision
• Double Vision

Those who suffer from visual disturbances will generally notice that they start in the center of their field of vision and will move outward toward the edges of the vision field before the full blown VM headache attack begins.

30 - 80 % of people who suffer with persistent VM experience vomiting, nausea, or motion sickness.

About 14 % of adult population of US has a migraine (2013) and Vestibular Migraine accounts for approximately 8% of migraines.

Up to 38% of people diagnosed with VM experience auditory symptoms. These include tinnitus, hearing loss, and ear pressure.

About Confusion in Diagnosis

Dizziness is a common symptom of a variety of illnesses.

Indeed, approximately 15 % of the general population experiences dizziness each year. As such it is often difficult to distinguish VM from other issues.

Doctors may experience difficulty determining if a patient is dealing with VM or Meniere’s Disease.

VM may also be originally diagnosed as vertigo.

Symptoms of VM may be similar to symptoms of acoustic neuroma, vascular abnormalities, brain stem lesions, post traumatic headache or vertigo, MS, stroke, and some infections.

Doctors must also consider other headache diagnoses like tension-type headaches, cluster variant headaches, paroxysmale hemicranie, chronic daily headaches, and migraine headaches with or without aura.

Vestibular Evoked Myogenic Potentials (VEMP) testing may be helpful in differentiating between migraine headaches and Meniere’s syndrome of BPPV.

VEMP testing applies a repetitive sound to an ear and measures the muscle activity that occurs in response to the stimulus. VEMP measures are commonly hyper responsive after an individual experiences a migraine.

The affected ear response measures as hyporesponsive with Meniere’s Syndrome. The affected ear latency response will be represented as prolonged with BPPV.

Here's a great resource to learn how VEMP test works.

Diagnostic Criteria

Your doctor will use the following criteria to determine the diagnosis of Vestibular Migraine.

You must have a diagnosis of, or a history of:

1. migraine without aura
2. migraine with aura

You must have experienced at least five episodes of:

Vestibular symptoms of moderate or severe intensity lasting between 5 minutes and 72 hours

And

At least half of the episodes include at least one of the following 3 migraine features

• Sensitivity to light or sound
• A visual aura
• Headache with at least 2 of the 4 characteristics: Unilateral location (pain on one side of the head), Pulsating nature, Moderate to severe intensity, Increases with physical activity

Which Tests are Appropriate?

There is no blood test or imaging test that will determine that a person is suffering from VM. However, your doctor will conduct a thorough evaluation to help establish a diagnosis.

You can expect a thorough medical history, a physical examination, and diagnostic tests to be taken to rule out other illnesses.

Blood tests may be ordered to rule out infections that can create symptoms similar to VM.

Your doctor may also order an MRI (Magnetic Resonance Imaging) scan or CT (Computed Tomography) scan to look at your brain,and you may be given hearing and balance tests to rule out issues with your ears.

MRI and CT scans may be ordered to rule out TIA (Transient Ischemic Attacks), or mini strokes.

Although symptoms resulting from a TIA are temporary, it is essential that your doctor rules out this diagnosis as TIA’s increase a person’s risk of suffering a stroke which could result in permanent damage to brain tissue.

Both CT scans and MRI’s can be run with or without a dye or contrast agent.

A Vestibular Evoked Myogenic Potentials (VEMP) tests may be ordered to support differentiation between migraine headaches, Meniere’s Syndrome, and BPPV.

Magnesium

Migraine can be effectively treated with oral magnesium supplementation (Obermann 2014; Peikert 1996; Chiu 2016), and magnesium supplementation may be beneficial in migraine-associated vertigo. A thorough analysis of randomized clinical trials found that, in cardiac patients, magnesium orotate supplementation reduced the risk of dizziness by 78% (Torshin 2015). Magnesium modulates smooth muscle tone in blood vessels (Kolte 2014), suggesting it might favorably impact vertigo related to vestibular blood flow restriction.

• Magnesium deficiency is a common underlying cause of vertigo. Magnesium is an essential mineral to balance Calcium levels in the circulation. An influx of Calcium concentrations may cause hardening of the small capillaries which feed the circulation to the ears. Foods which are high in Magnesium are nuts and seeds, green leafy vegetables, soy beans, brewers yeast, cacao, molasses and wholegrain cereals
• Take a Magnesium supplement to address deficiency, 80% of people have a need for higher levels of Magnesium due to refined or poor diets, stress, smoking, nervous system disorders or nutritional deficiencies* Consider increasing your Vitamin
• C and Bioflavinoid stores by taking a supplement which contains these. You may need to take between 5-10g of Vitamin C daily to address a chronic deficiency.
  

Some of the References used for this post:

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5. https://vestibular.org/migraine-associated-vertigo-mav
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