What Is Vestibular Migraine

Introduction

Vestibular disorders are caused by problems in the inner ear and can significantly affect the body’s delicate balance system, and among these disorders, vestibular migraines stand out as a unique challenge. Characterised by symptoms of dizziness known as vertigo, vestibular migraines bring an added layer of complexity to migraine disorders.¹ Vestibular migraines represent the most common cause of spontaneous vertigo, and it affects around 10% of people who experience migraines.² Treatment involves identifying what triggers these migraine attacks and how to prevent the occurrence - only a fraction of patients need medication. While there is not yet a cure for this disorder, lifestyle regulation has been shown to help 80-90% of people who experience vestibular migraines.² This article will shed light on the symptoms, diagnosis, triggers, treatment options and the promising role of lifestyle adjustments in vestibular migraines. 

Understanding migraines

A common misconception is that a Migraine is just a headache. At the same time, it is true that the two most prevalent types of migraine present with headaches; there are many other types that don't involve headaches at all. Vestibular Migraines can last from seconds to days, and while they typically occur in the absence of headaches, many can be followed by them along with visual disturbances.

The common symptoms of typical migraines include: 

• Pain felt on one side of the head.³ 
• Nausea and vomiting³
• Fatigue³ 
• Blurred vision³ 
• Confusion³ 
• Increased sensitivity to light.³

The main symptom of a vestibular migraine is dizziness, but other common symptoms include: 

• Vertigo⁴
• Nausea and vomiting⁴
• Sensitivity to light and loud sounds⁴
• Intolerance of movement (moving the head or moving objects that worsen symptoms)⁴
• Visual changes: blurred vision or lights flashing⁴ 
• Memory problems (during the episode)⁴
• Extreme tiredness⁴

The vestibular system

The body is able to maintain balance and a sense of position thanks to the Vestibular system. Think of it as your internal GPS, providing crucial information about your body’s movement. Its role in balance and spatial orientation lies in the system's ability to control the six degrees of rotational and translational movement of your head.⁵ Rotational movement is turning or spinning your head, and translational movement can be described as moving in a straight line, for example, walking down the street is a translational movement. The system's involvement in migraines is thought to be down to something called Cortical Spreading Depression (CSD). CSD represents a temporary ‘power outage’ in the brain that causes a disruption in normal brain activity. Although this sounds scary, it is not harmful in the long run but may explain disorders such as Vestibular Migraines and its foundation in sensory disruption.⁶ It is thought that CSD waves can reach the area of the brain that contains the vestibular cortex and all its machinery and cause the various symptoms associated with the function of this structure.  

Vertigo and visual disturbances

Vertigo has been defined as the sensation of moving or spinning and has other associated symptoms such as loss of balance, nausea and vomiting.⁷ The key distinction between vertigo and dizziness is that vertigo involves the false sensation of movement. It falls under the umbrella term of dizziness, but vertigo is the only type that causes the specific spinning feeling.⁸ 

Visual disturbances, sometimes referred to as visual auras, include bright lights, dots, zigzag lines, blurred, and double vision.⁹  Additionally, more than 90% of people who suffer from vestibular migraines experience sensitivity to light where they have negative or painful reactions to light during their episode, often being one of the first symptoms to present.¹⁰ 

Diagnosis

The diagnosis of vestibular migraines is based entirely on the clinical features as there are no biological markers of the condition, just like the majority of migraines.⁴ While researchers have defined some pathological components of vestibular migraines, such as nystagmus (involuntary eye movements during an episode), these tests are not readily available to most patients and remain excluded from the diagnostic criteria.¹¹ 

The official current diagnostic requirements for vestibular migraines are: 

• History of experiencing migraines with or without aura¹²
• A minimum of half of all episodes fulfil at least one of the following:
  • Headache that is on one side of the head, moderate to severe, pulsating or aggravated by a physical activity¹² 
  • Sensitivity to light and sound¹²
  • Visual aura¹²
• Symptoms must be moderate to severe with episodes lasting between 5 minutes to 72 hours  and must include:
  • Various types of vertigo¹² 
  • Head motion-induced dizziness¹² 
  • Nausea associated with the above 
• Other causes of symptoms must be excluded before a vestibular migraine diagnosis can be made

One of the main difficulties of diagnosing a vestibular migraine is the symptom overlap with Menières disease. Episodes of both of these disorders can be very similar in nature and can often be misdiagnosed without professional expertise, such as migraine headaches because auras and sensitivity to light are also prevalent in Menières disease.¹³ Importantly, vestibular migraines don’t progress to profound hearing loss like in Menières disease, and differentiation between the two disorders can become easier after the first year from the onset of symptoms.¹⁴

Other possible conditions that could be confused with vestibular migraines during diagnosis  include:

• Benign paroxysmal positional vertigo (BPPV): BPPV symptoms include vertigo, nausea and panic but only in short episodes¹⁵ 
• Transient ischemic attacks (TIAs): TIAs are a type of stroke that includes a sudden severe headache with little to no history of previous migraine attacks¹⁶
• Vestibular paroxysms: Brief attacks of vertigo that can occur multiple times a day¹⁷ 
• Psychiatric dizziness: some people who experience depression and anxiety can experience dizziness with their disorders; more than 50% of people who have vestibular migraines have related psychiatric disorders¹⁸ 

Triggers 

The top 5 most common triggers for vestibular migraines are: 

1. Stress and anxiety (the most common trigger)^19,20
2. Disordered sleeping: poor quality sleep, too little or too much sleep^19,20
3. Dehydration and hunger: lack of both and/or irregular meals^19,20
4. Dietary triggers:
   • Drinks: caffeine, alcohol, energy drinks^19,20
   • Foods: chocolate, citrus, certain cheeses and various food additives^19,20 
5. Hormonal changes: menopause, periods^19,20

There are also common environmental triggers: 

• Forms of lighting: bright lights, flashing, glaring, strip lighting etc.¹⁸ 
• Strong smells: aftershaves, perfumes¹⁸ 
• Weather changes¹⁸
• Smoky environments¹⁸ 
• Loud noises¹⁸

Risk factors

While the clinical populations that experience vestibular migraines can be highly variable, there have been large-scale studies that investigate risk factors in association with the condition. A recent study found that vestibular patients were more likely to be female, depressed, post-menopausal, and prone to motion sickness and food-triggered headaches. Any age group can experience²¹ Vestibular migraine attacks but are most commonly found in young adults and people between 60-70 years old.¹⁷ Studies also show the type of vestibular symptoms in association with migraines vary for each age group. For example, younger people are more likely to experience various types of vertigo and more likely to receive a full diagnosis. In contrast, older people experience more symptoms of dizziness and are more likely to receive the diagnosis of probable vestibular migraine.²² 

Most cases of vestibular migraines occur sporadically; there is some evidence of familial occurrence, which suggests a genetic component for some individuals.²³ People with siblings who experience vestibular migraines are thought to be at a 4-10 times greater risk than the general population.²⁴ 

Treatment options

Prescribing medication is not the first-line treatment for vestibular migraines. Painkillers and prevention medicines can be used for their management. However, there is a huge emphasis on making lifestyle changes to avoid the attacks. This can include avoiding triggers, managing stress and maintaining a healthy sleeping pattern. A recent study investigated the effects of lifestyle modification in people with a diagnosis of vestibular migraines and found improvement in the symptoms of dizziness and headache in up to 39% of the participants.²⁵ 

Lifestyle modifications:

Reducing the intake of identified trigger foods has been shown to alleviate the symptoms of the condition in up to 72% of patients.²⁰ Diet interventions show that low-fat and elimination diets relate to a decrease in the attacks of various types of migraines.²⁶ The Vestibular Disorders Association even recommend supplements such as magnesium, riboflavin and vitamin D.²⁷ 

Elevated stress levels commonly go hand in hand with vestibular dysfunction in general.²⁸ This is why most healthcare practitioners will recommend stress management for treating vestibular migraines. Some people find meditation a productive form of stress management - it can even be done at home virtually through websites such as https://www.meditatelondon.co.uk/.²⁹

Poor sleep quality has long been associated with people who suffer from vestibular disorders, including reduced REM/slow wave sleep, lighter sleep and increased amount of time to fall asleep.30 There are NHS-recommended apps that can help with improving sleep, such as: 

• Sleepio: based on Cognitive Behavioural Therapy, available on the NHS website³¹
• Headspace: mindfulness and meditation for stress, resilience and sleep aid, NHS recommended and free for NHS staff³² 

There is also an app that can help track and identify migraine triggers, an effective way to know how to manage your lifestyle in a way that can help! Migraine Buddy is free to use and was designed closely with neurologists; it can even export collected data to share with your healthcare provider.³³ 

Medications:

Although medical management is not the first line of treatment for the condition, drugs are sometimes used for the prevention of migraine headaches. These include beta-blockers, calcium blockers, anticonvulsants and antidepressants.³⁴ Recent evidence suggests that the long-term management of migraines is best maintained with a combination of preventative medicines and lifestyle modifications as opposed to either of the two in isolation.³⁵

Studies show that various medications can improve the symptoms of migraine attacks; however, it does relate to the severity of the vestibular symptoms. For example, the longer the symptoms last, the greater the effect of the drug in alleviating those symptoms.³⁶ Overall, there is no positive consensus for the use of medications to treat this type of migraine as much of the scientific evidence is weak. A recent review concluded that while there was some evidence to suggest a slight improvement in the symptoms associated with vestibular migraines, it isn’t enough to draw any meaningful conclusions.³⁷ Furthermore, there is little research on long-term use and the potential harms of using pharmacological interventions.

Vestibular rehabilitation therapy:

Vestibular Rehabilitation (VR) therapy is used to treat the symptoms of migraine attacks, including dizziness and balance dysfunction.³⁸ This therapy seeks to improve vertigo symptoms, improve activities involved in daily living and enhance gaze and postural stability. It is based on a series of exercises that revolve around head/eye movement, posture, maintaining balance while carrying out tasks and exposure to different motor and sensory environments.³⁹

Summary

It is evident that the path to alleviating the symptoms of vestibular migraines often begins with lifestyle adjustments. While there is no definitive cure for the challenging condition, adjustments can make profound improvements to the quality of life of individuals who suffer from this type of migraine. Understanding vestibular migraines involves recognising that they are more than just headaches - the condition encompasses a spectrum of distressing symptoms. From vertigo to extreme fatigue, these symptoms can be debilitating. One of the key takeaways is the importance of adapting your lifestyle in order to adopt effective management strategies. For many, these modifications can be game-changing in offering relief from the burdens of vestibular migraines. Dietary adjustments, stress management, and improved sleep can help to reduce the severity of episodes. Healthcare practitioners emphasise the avoidance of triggers so you can regain control over your life. This approach is proactive and sustainable; you can take charge of your own well-being and reduce reliance on pain relief medication. While there may not be a one-size-fits-all solution, the power of leading a healthy and balanced lifestyle while avoiding your triggers should not be underestimated.