Introduction

Many parts of the brain can be affected in a migraine attack which means a wide range of symptoms can occur. When brain circuits for balance are affected, a person will experience symptoms of dizziness, which is known as vestibular migraine. This can also be known as migraine-associated vertigo or migrainous vertigo. 

The vestibular system is in the inner ear and controls your balance and perception of movement. With vestibular migraine, there is a problem processing the turning and tilting signals in the brain, making patients very sensitive to motion. Most people with vestibular migraine have a lifetime history of motion sickness. This faulty processing can also impact vision signals from the eyes and motion signals from the inner ears which is important to normal balance. Many people have difficulty when objects are flowing by.¹

Understanding vertigo

Vertigo is a sense of rotation, rocking or the world spinning, experienced even when someone is perfectly still. There are two possible causes for vertigo: 

• Peripheral vertigo: refers to the disorders that involve disturbances in the inner ear. The common disorders that may affect the inner ear thereby causing the person to experience dizziness or vertigo include: vestibular neuritis (inflammation of the vestibular nerve which is responsible for taking the nerve impulses from the semicircular canals in the inner ear to the brain), labyrinthitis (inflammation of the labyrinth which is also in the inner and most of the time may also involve the vestibular nerve). Both of these disorders are usually caused by a viral infection that may have reached the inner ear.²

• Benign paroxysmal positional vertigo (BPPV): his results from the movement of the otolith, which is a very small particle made of calcium inside the ear. The otolith organs detect the movement of your head and its relation to gravity. Sometimes, the otolith can be dislodged and move into the semicircular canals and affect the movement of the fluid inside, thereby causing it to send irregular nerve impulses to the brain, making the person get dizzy.³

Understanding migraines

The main symptoms of vestibular migraines include dizziness, vertigo and difficulties with balance. Symptoms can also include: nausea, vomiting, confusion, light sensitivity, sound sensitivity and ringing in the ears and feeling of pressure in the ears. Symptoms may be short and frequent or long-lasting or even continuous for weeks or months. It is important to know that you can have a vestibular migraine attack with or without a headache. These symptoms can be triggered by stress, weather, hormones, lack of sleep, dehydration, lack of sleep and smoking.⁴

The connection between vertigo and migraines

The connection between migraines and vertigo is key. A new study published in the Journal of Headache and Pain, took this theory a step further. It discovered a hidden connection between the two. To investigate the relationship between migraines and vertigo the researchers analyzed the data collected by the Migraine and Neck Pain Study. This study included questionnaire-derived information from 487 migraine sufferers. They asked these sufferers whether and when they suffered from vertigo and divided the vertigo into three time frames:

• Constant vertigo and other migraine symptoms at the beginning of the headache
• Constant vertigo and other migraine symptoms that began less than two hours before the migraine auras and pain
• Vertigo, constant or otherwise, and other migraine symptoms occurring two to 48 hours before the headache

The migraine-suffering patients had to report which of these three groups their vertigo and other migraine symptoms would be classified under. Altogether, 30% of people reported having vertigo at some point during their migraines. 16% had it at the beginning of the headache, 10% had it within two hours of the headache and 3% had between two to 48 hours prior to the headache. Both the groups whose migraines were accompanied by auras and people who suffered migraines without auras suffered vertigo in approximately the same amounts, at the same times. This is why many scientists refer to these people as suffering from vestibular migraines. However, the international classification of Headache disorders still doesn't classify the vestibular migraines as a separate disorder. To study, they estimated that 26% of their participants suffered from vestibular migraine. This disorder is so varied from a normal migraine that many sufferers don't even experience headaches at all. They experience vertigo, nausea, vomiting and sensitivity to sound. Therefore, they might not even realize they are having a migraine attack.⁵

Both migraines and vertigo are caused by a lack of blood flow up to and throughout the head and brain area. The solution is therefore to use simple exercises that allow more blood to be pumped up to the brain and throughout the head through the day and night.

Diagnosis of vertigo and migraines

Vertigo

• Clinical history and symptoms
• Blood tests: to check for infection
• The Romberg test: where the doctor will have the patient stand with their eyes open and feet together, then maintain balance while their eyes are closed
• Vestibular testing: to check for any involuntary movements of the eyes (nystagmus)
• Fukunda-underberger test: the patient will have to close their eyes and march in place while trying not to lean to the side
• Diagnostic imaging tests: T scan or MRI to rule out central causes of vertigo or any tumor present⁶

 Migraines

• Detailed analysis of medical history 
• Effects of migraines on daily activities 
• Family history of migraines/headaches 

For an accurate diagnosis, individuals must visit the ENT department or a neurotologist. 

Treatment approaches 

Pharmacological approaches for migraines:

• Pain relievers: over-the-counter medication such as Aspirin and Ibuprofen 
• Triptans: Prescription drugs such as sumatriptan (Imitrex, Tosymra) and rizatriptan (Maxalt, Maxalt-MLT)
• Dihydroergotamine: A nasal spray for migraines lasting more than 24 hours

Anti-nausea drugs

• Opioid medications: if the migraine with aura is accompanied by nausea and vomiting. These include chlorpromazine, metoclopramide (Gimoti, Reglan) or prochlorperazine (Compro, Compazine). These are often taken with pain medications.⁷

Vertigo treatment - depends on the causative factor Peripheral vertigo can be treated by bed rest, avoiding sudden position changes and use of Vestibular Blocking Agents or VBAs. The medication helps relieve the inflammation in the inner ear, relaxes the muscles and prevents other symptoms.⁸

Pharmacological approaches for vertigo:

• Prochlorperazine
• Antihistamines: such as cinnarizine, cyclizine and promethazine

Non-medicinal treatments such as neuromodulation devices, cognitive behavioral therapy (CBT), vestibular physical therapy and coenzyme Q10, magnesium and riboflavin (vitamin B2) may also help.⁸

FAQs 

What is the difference between PPPD and vestibular migraines?

PPPD also known as Persistent Postural Perceptual Dizziness, typically tends to come and go within 20 minutes or an hour or two and vestibular migraines tend to come with visual spotting and dizziness. 

What are the triggers for a migraine?

Migraines can be triggered by many things such as lack of sleep, dehydration, stress and anxiety, alcohol, caffeine and certain foods such as cheese, processed foods or artificial sweeteners.

Summary

There is a clear link between migraines and vertigo as mentioned previously. Migraines can cause dizziness which can lead to vertigo. Therefore, it is essential that the individual visit the neurotologist for an accurate diagnosis and take preventive medication to help relieve symptoms.