Dizziness and Migraine: When is it Vestibular Migraine?
Posted on August 07 2025,
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Dizziness and Migraine
When is dizziness vestibular migraine, and when is it something else?
Understanding Dizziness
Dizziness is a common symptom, but determining the cause can be challenging. Among the many possible causes, vestibular migraine has emerged as a leading explanation for recurring dizziness episodes.
Statistics
Vestibular migraine is now recognized as the most common cause of spontaneous episodic vertigo. About 50% of people with migraine experience dizziness, and vestibular migraine affects up to 2.7% of the general population.
The Challenge of Diagnosis
Vestibular migraine is often called "the chameleon of vestibular neurology" because it can mimic many other conditions. It overlaps significantly with:
- Benign paroxysmal positional vertigo (BPPV): Brief episodes of spinning triggered by head position changes, caused by loose crystals in the inner ear
- Meniere's disease: Episodes of vertigo with hearing loss, tinnitus, and ear fullness, thought to be caused by fluid buildup in the inner ear
- Persistent postural-perceptual dizziness (PPPD): Chronic dizziness that worsens with upright posture, movement, and complex visual environments
- Even posterior circulation strokes in some cases
The key is understanding the pattern of symptoms, timing, and associated features that help distinguish vestibular migraine from other causes of dizziness.
Clinical Decision Tree
This very general systematic approach may help determine whether dizziness is likely due to migraine or requires investigation for other causes.
Step 1: What triggers your dizziness?
Step 2: How long do episodes last?
Step 3: Do you have hearing symptoms?
Step 4: Do you have migraine-related symptoms?
Final Assessment
HIGH likelihood of Vestibular Migraine if:
- Spontaneous dizziness lasting minutes to days
- Light/sound sensitivity or nausea during episodes
- Personal or family history of migraine
- Triggered by stress or hormones
Consider OTHER causes if:
- Only positional dizziness lasting seconds
- Progressive hearing loss in one ear
- Age >65 with cardiovascular risk factors
- Neurological symptoms (weakness, speech problems)
For Clinicians: Quick Assessment Questions Based on Above
- Do you have a history of migraine or motion sickness?
- Are there family members with migraine?
- Do you experience light or sound sensitivity during dizzy episodes?
- Are episodes triggered by stress or hormonal changes?
- Do you feel nauseous during dizzy spells?
Vestibular Migraine: The Chameleon
Full Guide to Vestibular MigraineCore Features of Vestibular Migraine
Vestibular migraine (VM) is the most common cause of spontaneous episodic vertigo, yet it remains frequently misdiagnosed because it can mimic virtually every other vestibular disorder - like a chameleon.
Diagnostic Criteria
- Duration: Minutes to 72 hours (30% last minutes, 30% hours, 30% days)
- Character: Spontaneous or positional vertigo, dizziness, or unsteadiness
- Associated features: Migraine symptoms (headache, photophobia, phonophobia) during at least 50% of episodes
- History: Current or previous migraine diagnosis
The CGRP Connection
Calcitonin Gene-Related Peptide (CGRP) plays an important role in both migraine and vestibular symptoms. CGRP is expressed in vestibular nuclei and the inner ear, acting as a "gain modulator" for sensory signals. This explains why CGRP-blocking medications show promise for treating vestibular migraine, with studies showing up to 90% of patients achieving 50% reduction in vertigo frequency.
Unique Challenges in Diagnosis
Vestibular migraine can present with:
- Central positional nystagmus that mimics BPPV
- Hearing changes that resemble Ménière's disease
- Persistent symptoms that look like PPPD (Persistent Postural-Perceptual Dizziness)
- Acute presentations that can be mistaken for stroke
Cutaneous Allodynia: Impacts VM Migraine Treatment
Cutaneous allodynia - when normal touch becomes painful - affects over 60% of migraine patients and is as a critical marker of central sensitization. Understanding allodynia is essential because it:
- Predicts treatment resistance (triptans lose 60-80% effectiveness once allodynia develops)
- Increases risk of migraine progression to chronic form
- Correlates with suicide risk when combined with osmophobia (smell sensitivity)
- Indicates need for aggressive preventive treatment (more on this later)
Suicide Risk
Patients with both cutaneous allodynia AND osmophobia have 3.12 times higher suicide risk - the strongest predictor, even stronger than depression alone. Screen for both symptoms and assess mental health accordingly.
Recognizing Allodynia
Common Allodynia Triggers During Migraine
- Pain when combing or brushing hair
- Discomfort from wearing glasses or earrings
- Pain from resting head on pillow
- Sensitivity to light touch on face or scalp
- Discomfort from tight clothing
- Pain from shower water hitting skin
Clinical Pearl: Treatment Timing
Once allodynia develops during an attack, standard acute medications become much less effective. Patients must be educated to treat at the very first sign of migraine, before allodynia onset. If allodynia is already present, consider DHE, injectable ketorolac, or intranasal lidocaine instead of triptans.
The Science Behind Allodynia
Allodynia develops through central sensitization, where the brain's pain processing system becomes oversensitive. This involves:
- Trigeminal sensitization: The trigeminal nerve system becomes hyperactive
- Thalamic involvement: The thalamus amplifies pain signals inappropriately
- Spinal sensitization: In severe cases, spinal cord pain pathways become hyperactive
BPPV vs Vestibular Migraine
Benign paroxysmal positional vertigo (BPPV) is the most common cause of triggered dizziness, especially when rolling over in bed or looking up. However, people with migraine are twice as likely to develop BPPV, and the two conditions can coexist.
| Feature | BPPV | Vestibular Migraine |
|---|---|---|
| Trigger | Position changes (rolling in bed, looking up) | Can be positional or spontaneous |
| Duration | Seconds to 1 minute | Minutes to hours to days |
| Associated Symptoms | Nausea (but usually brief) | Light/sound sensitivity, headache, nausea |
| Response to Treatment | Improves with repositioning maneuvers | Often needs migraine-specific treatment |
| Pattern | Consistent response to same positions | Variable triggers and responses |
When Both Conditions Coexist
If you have both BPPV and vestibular migraine, BPPV treatments may be less effective, and episodes may recur more frequently. In these cases, treating the underlying migraine becomes important for overall improvement.
What to Expect
If your healthcare provider suspects BPPV, they'll perform positioning tests to see if they can reproduce your symptoms and observe specific eye movements. If these maneuvers help, you likely have BPPV. If they don't provide lasting relief, or if you have additional migraine symptoms, vestibular migraine should be considered.
Meniere's Disease vs Vestibular Migraine
Meniere's disease and vestibular migraine can be very similar, and recent research suggests up to 60% of people diagnosed with Meniere's disease may actually have vestibular migraine or both conditions.
| Feature | Meniere's Disease | Vestibular Migraine |
|---|---|---|
| Episode Duration | 20 minutes to several hours | Minutes to hours to days |
| Hearing Loss | Progressive, low-frequency, typically one ear | Temporary, fluctuating, often both ears |
| Tinnitus | Usually one ear, low-pitched | Variable, may affect both ears |
| Ear Fullness | Usually one ear, pressure-like | Common but fluctuating |
| Migraine Symptoms | Usually absent | Light/sound sensitivity, headache, nausea |
| Response to Salt Restriction | Often improves symptoms | Minimal effect |
| Response to Migraine Treatment | Minimal effect | Often significant improvement |
The Overlap Challenge
Recent research shows that vestibular migraine can mimic every major symptom of Meniere's disease, including hearing loss and tinnitus. This is why many experts now recommend trying migraine preventive treatments before considering irreversible procedures for presumed Meniere's disease.
Diagnostic Approach
If you have symptoms that could be either condition, your healthcare provider may:
- Order hearing tests to look for specific patterns of hearing loss
- Consider specialized vestibular testing
- Try migraine preventive treatments as a therapeutic trial
- Look for other migraine-related symptoms or family history
When Dizziness Might Be Vascular
While most dizziness isn't dangerous, certain patterns raise concern for vascular causes, including stroke or transient ischemic attacks (TIAs) affecting the posterior circulation of the brain.
High-Risk Features for Vascular Causes
- Age over 65 with new-onset dizziness
- Diabetes, hypertension, or atrial fibrillation
- New severe neck pain with dizziness
- Focal neurologic symptoms: weakness, numbness, vision changes
- Severe imbalance or inability to walk
- Male gender with cardiovascular risk factors
The Sudbury Vertigo Risk Score
Risk Assessment Tool
Healthcare providers may use scoring systems to assess stroke risk in dizzy patients. The Sudbury Vertigo Risk Score considers factors like age over 65, male sex, diabetes, hypertension, and neurological symptoms to determine if further vascular investigation is needed.
Some Differences from Migraine
- Sudden onset: Vascular events typically start abruptly
- Neurological signs: Weakness, speech problems, vision changes (may appear in migraine attacks)
- Severe instability: Unable to walk or stand without support
- No migraine features: Lack of light sensitivity, nausea, or headache patterns
Important Point for Migraine Patients
If you have a history of migraine but experience a new type of dizziness that's different from your usual pattern, don't assume it's "just migraine." New-onset symptoms in someone with vascular risk factors should be evaluated promptly.
Treatment Approaches
Treatment Based on Allodynia Status
No Allodynia Present
- Standard acute medications effective (triptans, NSAIDs)
- Emphasize early treatment at first symptom
- Consider preventive if ≥4 attacks/month
Allodynia Present
-
Acute options that maintain efficacy:
- Dihydroergotamine (DHE) - maintains full efficacy
- Injectable ketorolac
- Intranasal lidocaine (rapid onset 5-15 minutes)
- Symbravo (newest FDA-approved option)
- Aggressive prevention essential
Preventive Treatment for Vestibular Migraine
90%
respond to CGRP antibodies
16-24
weeks needed for full response with allodynia, maybe longer for select patients (those with anxiety/depression and/or obesity)
First-Line Preventives for VM with Allodynia
- CGRP monoclonal antibodies: Superior efficacy for both vertigo and allodynia
- Botulinum toxin: For chronic migraine with VM
- Topiramate: Multiple anti-allodynia mechanisms
- Amitriptyline: Specific anti-allodynic properties
- Vestibular rehabilitation: Essential adjunct therapy
Treatment Timeline
Patients with established allodynia often need longer treatment trials. While standard trials last 8-12 weeks, those with allodynia may need 16-24 weeks to see full benefit, especially with CGRP antibodies. This reflects the time needed to potentially reverse central sensitization.
If It's Vestibular Migraine
Treatment focuses on:
- Lifestyle modifications: Regular sleep, stress management
- Preventive medications: Similar to regular migraine prevention
- Acute treatment: May require different approaches than typical migraine medications
- Vestibular rehabilitation: Specialized physical therapy for balance
- CGRP inhibitors: New medications showing promise for vestibular migraine
If It's BPPV
- Canalith repositioning maneuvers (like the Epley maneuver)
- Usually resolves quickly with proper treatment
- May require treating underlying migraine if recurrent
If It's Meniere's Disease
- Low-sodium diet and diuretics
- Sometimes requires more invasive treatments if severe
- Many patients benefit from migraine preventive treatments
If It's Vascular
- Immediate treatment of underlying cardiovascular issues
- Blood thinners or other stroke prevention medications
- Management of risk factors like diabetes and hypertension
Key Takeaways for Patients
Questions to Ask Your Doctor
- "Could my dizziness be vestibular migraine?"
- "Should I be screened for cutaneous allodynia?"
- "Am I treating my migraine attacks early enough?"
- "Would CGRP therapy help my vestibular symptoms?"
- "Do I need vascular workup for my dizziness?"
Self-Monitoring
Track these patterns in your diary/journal:
- Does dizziness occur with migraine features (light/sound sensitivity)?
- Do you develop skin sensitivity during attacks?
- How long does dizziness last (seconds, minutes, hours, days)?
- What triggers it (position changes, stress, hormones)?
- Does migraine treatment help the dizziness?
Remember These Points
- Dizziness is common and most causes are not dangerous, but proper diagnosis matters for effective treatment
- Vestibular migraine is now the most common cause of recurrent dizziness episodes
- Family history of migraine makes vestibular migraine more likely
- Multiple conditions can coexist - having one doesn't rule out others
- Treatment approaches differ significantly between conditions
Bottom Line
If you're experiencing recurrent dizziness, especially with a personal or family history of migraine, consider that vestibular migraine might be the cause. However, don't self-diagnose - work with your healthcare provider to rule out other conditions and develop an appropriate treatment plan.
AGAIN, DO NOT MISS VASCULAR CAUSES!
12-22% of patients who develop posterior circulation stroke had transient vestibular symptoms in the preceding 3 months. New spontaneous episodic dizziness in patients with vascular risk factors warrants evaluation, even if they have migraine history.
Always consider vascular causes in patients over 65 with new-onset dizziness, especially with cardiovascular risk factors. The Sudbury Vertigo Risk Score can help stratify patients who need urgent vascular workup.
Disclaimer
This article is for educational purposes based on current research and clinical guidelines. The information provided should not be used as a substitute for professional medical advice, diagnosis, or treatment. Always consult with qualified healthcare providers about your specific medical conditions and treatment options.
References
- Baron R, Steenerson KK. Dizziness: When Is It Migraine, and When Is It Not? Current Neurology and Neuroscience Reports. 2025;25:56.
- Sruthi KS, Rajkumar E, Gopi A, Julia GJ, Romate J. Risk Factors and Consequences of Cutaneous Allodynia among Individuals with Migraine: A Scoping Review. Current Pain and Headache Reports. 2025;29(102).
- Sharon JD, Krauter R, Chae R, Gardi A, Hum M, Allen I, Levin M. A placebo controlled, randomized clinical trial of galcanezumab for vestibular migraine: The INVESTMENT study. Headache. 2024;64:1264–1272.
- Lipton RB, Bigal ME, Ashina S, et al. Cutaneous allodynia in the migraine population. Ann Neurol. 2008;63(2):148–58.
- Dodick DW, Reed ML, Fanning KM, et al. Predictors of allodynia in persons with migraine: results from the Migraine in America Symptoms and Treatment (MAST) study. Cephalalgia. 2019;39(7):873–82.
- Park SP, Seo JG, Lee WK. Osmophobia and allodynia are critical factors for suicidality in patients with migraine. J Headache Pain. 2015;16:529.
- van Patot ET, Roy D, Baraku E, et al. Validation of the Sudbury Vertigo Risk Score to risk stratify for a serious cause of vertigo. Acad Emerg Med. 2025.
- Kim J-S, Newman-Toker DE, Kerber KA, et al. Vascular vertigo and dizziness: Diagnostic criteria. J Vestib Res. 2022;32:205–222.
- Edlow JA, Bellolio F. Recognizing posterior circulation transient ischemic attacks presenting as episodic isolated dizziness. Ann Emerg Med. 2024;84:428–438.
- Russo CV, Saccà F, Braca S, et al. Anti-calcitonin gene-related peptide monoclonal antibodies for the treatment of vestibular migraine: A prospective observational cohort study. Cephalalgia. 2023;43:3331024231161809.
- Staab JP, Eggers SDZ, Jen JC, et al. Rizatriptan vs. placebo for attacks of vestibular migraine: A randomized clinical trial. JAMA Neurol. 2025.
- Pijpers JA, Kies DA, van Zwet EW, et al. Cutaneous allodynia as predictor for treatment response in chronic migraine: a cohort study. J Headache Pain. 2023;24(1):118.
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