Approximately 40% of migraine suffers experience significant vestibular symptoms: vertigo or balance disturbances before an attack or as the main symptom. Persistent vertigo is often misdiagnosed as a vestibular disease and people can spend a long time trying various treatments without success.
What is vestibular migraine?
The word “vestibular” relates to the inner ear: one of the balance centres in the human body. This can also be classified as “migraine associated dizziness” but dizziness is just part of the story.
Diagnostic criteria for vestibular migraine include:
• Balance disturbance
• Room spinning dizziness (Vertigo)
• Motion intolerance
• Other migrainous symptoms such as sensory sensitivity, headache, disorientation and nausea/vomiting.
This is commonly missed when the headache is not the main feature. There is an association with other vertiginous conditions such as paroxysmal vertigo of childhood and recurrent benign positional paroxysmal vertigo (BPPV) in adults but the link is still unclear. The mechanism that causes vestibular symptoms is unclear, but it is thought to be another manifestation of migraine aura.
When should I suspect vestibular migraine?
Vestibular migraine is often diagnosed as BPPV or acute neuronitis/labrynthitis (a viral infection of the inner ear causing similar symptoms) which does not respond to traditional treatments such as positional manoeuvres (Epley’s) or tablet vertigo treatments such as prochlorperazine and beta-histine. The headache symptoms are often missed and as nausea and vomiting are common features in both of those conditions, migraine can be overlooked.
If other migrainous features are present such as sensory sensitivity (to light, sound, smell, touch and movement), cognitive changes (memory loss, slowing of thoughts or brain function) or headache (head, neck or facial pain) are present then this should be suspected.
A number of patients suffer vestibular migraine without headache, and vestibular migraine should be suspected if vertigo persists and any of the above features are present. Unfortunately, like with all migraine, there are no diagnostic tests to confirm diagnosis.
How can it be treated?
Vestibular migraine tends to be stubborn to treatment. Managing triggers should be the first-line treatment for any migraine: eating regularly, having routine sleep, minimising or managing stress and managing hormonal variations are all examples of lifestyle measures which can be helpful.
Use of anti-vertigo medication (prochlorperazine and beta-histine) on a regular basis should be avoided, not only because they are ineffective for vestibular migraine, but they can also cause a “medication overuse headache” if they are used too often. This can cause symptoms to “ramp up” and can lead to persistent vertigo or balance issues.
Vestibular rehabilitation is the mainstay of treatment for most vestibular disorders: this is specialist physiotherapy which can help manage balance symptoms. Unfortunately, in vestibular migraine this is often ineffective and, in some circumstances, can make symptoms worse.
Migraine preventatives can be beneficial for vestibular migraine as they are in more “classical forms” of migraine. If you have more than 8 symptoms days per month a trial of one of these medications for at least 6 weeks at the optimum dose can be helpful in reducing symptom severity, and attack frequency. First line treatment is usually Amitriptyline or Nortriptyline started at a low dose and increased slowly to a maximum of 50-75mg at night.
How about nerve blocks?
Studies show that use of Greater Occipital Nerve blocks can help to reduced symptoms of dizziness. This is an injection of mixed steroid and local anaesthetic and the reasons behind its efficacy are unknown.
This information is provided as a general guide only and is not a comprehensive overview of prescribing information. If you have any queries or concerns about your headaches or medications please discuss them with your GP or the doctor you see at the National Migraine Centre.