Vestibular Migraine: The Essentials

Properly diagnosing Migraine can be tricky, especially when it comes to less common forms of Migraine, including Vestibular Migraine. There are several forms of Migraine, each with its own set of diagnostic criteria from the International Headache Society’s International Classification of Headache Disorders, 3rd Edition (ICHD-3). The ICHD-3 is the gold standard for classifying Migraine and other Headache disorders.

A major issue we continue to see is patients given a diagnosis of “Migraine,” which is an incomplete diagnosis. That diagnosis is incomplete because it doesn’t specify which form or forms of Migraine the patient has. A complete diagnosis using the ICHD-3 is critical for a number of reasons:

• Different people, including doctors, can mean different things when they talk about forms of Migraine if they’re not all on the same page.
• Some medications are not recommended for certain types of Migraine
• If we need to seek care from a health care professional other than those on our team, it’s important for them to know what form(s) of Migraine we have.
• When we’re looking for information or support, it can be difficult without a complete diagnosis.

Vestibular Migraine: The Essentials

Over the years, many people have talked about Vestibular Migraine, but there was no such diagnosis within the ICHD. In the third edition (ICHD-3), Vestibular Migraine has been addressed. The Classification Committee of the IHS has added it to the appendix in ICHD-3. The primary purpose of the appendix is to:

“…present research criteria for a number of novel entities that have not been sufficiently validated by research conducted so far. The experience of the experts in the Classification Committee, and publications of variable quality, suggest that there are still a number of diagnostic entities that are believed to be real but for which better scientific evidence must be presented before they can be formally accepted.”

It’s common for disorders that appear in the appendix of the ICHD to be moved to the main body in the next edition.

All of that said, what is Vestibular Migraine? In the past, it’s been called Migraine-associated vertigo/dizziness, Migraine-related vestibulopathy, and Migrainous vertigo. I’ll include the IHS description and diagnostic information below, but here are the basics:

1. For a diagnosis of vestibular migraine, there must be a history of migraine without aura or migraine with aura.
2. Vestibular migraine can occur with or without aura.
3. Mild or moderate vestibular symptoms between five minutes and 72 hours, including:
   • spontaneous vertigo:
     • internal vertigo (a false sensation of self-motion);
     • external vertigo (a false sensation that the visual surround is spinning or flowing);
   • positional vertigo, occurring after a change of head position;
   • visually induced vertigo, triggered by a complex or large moving visual stimulus;
   • head motion-induced vertigo, occurring during head motion;
   • head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
4. At least 50 percent of episodes are associated with at least one of the following three Migrainous features:
   • headache with at least two of the following four characteristics:
     • unilateral location
     • pulsating quality
     • moderate or severe intensity
     • aggravation by routine physical activity
   • photophobia and phonophobia
   • visual aura

Simplified definition

Vestibular Migraine is Migraine with Aura or Migraine without Aura with mild or moderate vestibular symptoms lasting between five minutes and 72 hours.

It can be difficult to know if we’re experiencing dizziness or vertigo.

• Dizziness is most often described as feeling faint or lightheaded.
• Vertigo is a sensation of motion in which the person or the person’s surroundings seem to whirl dizzily.

If you have trouble distinguishing between the two, make notes about how you feel as soon as possible, while it’s fresh in your mind, and discuss them with your doctor.

From ICHD-3:

A1.6.5 Vestibular Migraine

Diagnostic criteria:

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 aura1
3. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours4
4. At least 50% of episodes are associated with at least one of the following three migrainous features:
   1. headache with at least two of the following four characteristics:
      1. unilateral location
      2. pulsating quality
      3. moderate or severe intensity
      4. aggravation by routine physical activity
      5. photophobia and phonophobia
   2. photophobia and phonophobia
   3. visual aura
5. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.

Notes:

1. 1. Code also for the underlying migraine diagnosis.
   2. Vestibular symptoms, as defined by the Bárány Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of A1.6.5 Vestibular migraine, include:
      1. spontaneous vertigo:
         • internal vertigo (a false sensation of self-motion);
         • external vertigo (a false sensation that the visual surround is spinning or flowing);
      2. positional vertigo, occurring after a change of head position;
      3. visually induced vertigo, triggered by a complex or large moving visual stimulus;
      4. head motion-induced vertigo, occurring during head motion;
      5. head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
      6. Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued.
      7. Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.
      8. One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.
      9. Phonophobia is defined as sound-induced discomfort. It is a transient and bilateral phenomenon that must be differentiated from recruitment, which is often unilateral and persistent. Recruitment leads to an enhanced perception and often distortion of loud sounds in an ear with decreased hearing.
      10. Visual auras are characterized by bright scintillating lights or zigzag lines, often with a scotoma that interferes with reading. Visual auras typically expand over 5-20 minutes and last for less than 60 minutes. They are often, but not always restricted to one hemifield. Other types of migraine aura, for example somatosensory or dysphasic aura, are not included as diagnostic criteria because their phenomenology is less specific and most patients also have visual auras.
      11. History and physical examinations do not suggest another vestibular disorder or such a disorder has been considered but ruled out by appropriate investigations or such a disorder is present as a comorbid or independent condition, but episodes can be clearly differentiated. Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks.

Comments:

A surprisingly high prevalence of A1.6.6 Vestibular migraine of 10.3% was recently described among migraine patients in Chinese neurological departments.

Other symptoms:

Transient auditory symptoms, nausea, vomiting, prostration and susceptibility to motion sickness may be associated with A1.6.5 Vestibular migraine. However, as they also occur with various other vestibular disorders, they are not included as diagnostic criteria.

Summary and implications for patients:

We can work best with our doctors as treatment partners when we know our full diagnosis. If you’ve only been given a diagnosis of “Migraine,” ask your doctor to be more specific. This is also helpful when looking for more information and when talking with others.

Vestibular Migraine can occur with or without aura. A Migraine patient diagnosed with Vestibular Migraine will often be given multiple diagnoses. Our migraines aren’t always the same. Someone with Vestibular Migraine may not always have the vestibular symptoms, so will often also be diagnosed with Migraine with or without aura, or both, ending in three diagnoses – Vestibular Migraine, Migraine with Aura, and Migraine without Aura. As research continues, and doctors see more people who meet the ICHD-3 appendix criteria for Vestibular Migraine, it may well be moved into the main body of the ICHD in the next edition.

Source:

1. 1. Headache Classification Committee of the International Headache Society. “The International Classification of Headache Disorders, 3rd Edition (ICHD-3).” Cephalalgia, Volume: 38 issue: 1, page(s): 1-211.