Vestibular Migraine: Diagnostic Criteria and Evaluation

Approximately 10% of adults presenting to specialized dizziness clinics have vestibular migraine; approximately 35% of the patients in my neuro-otologic practice have vestibular migraine.
Sources.
Neuhauser HK, Leopold M, von Brevern M, et al. The interrelations of migraine, vertigo and migrainous vertigo. Neurology. 2001;56:436-441.
Dieterich M, Brandt T. Episodic vertigo related to migraine (90 cases): vestibular migraine? J Neurol. 1999;246:883-892.

Many names have been used to describe this entity including vertiginous migraine, migrainous vertigo, migraine-associated dizziness, and migraine-associated vertigo. The term vestibular migraine is preferable since patients may experience a wide range of vestibular symptoms, and not just vertigo. Spontaneous episodes of vestibular symptoms lasting anywhere from seconds to weeks (but most commonly the duration is minutes to 72 hours) are often accompanied by migrainous features (photophobia, phonophobia, typical migraine headache, and/or visual aura).

Some patients have positional vertigo; unlike benign paroxysmal positional vertigo, vestibular migraine-related positional vertigo often persists as long as the offending position is maintained, and is not fatigable. In 2012, diagnostic criteria were published to help with the diagnosis of vestibular migraine. Essentially, the diagnosis is made if patients experience at least 5 episodes of vestibular symptoms of at least moderate intensity (ie, enough to impair daily activities), each lasting between 5 minutes to 72 hours, with most episodes associated with migrainous manifestations (photophobia, phonophobia, headache, or visual aura).
Source: Lempert T, Olesson J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22:167-172.

It is important to exclude other causes of dizziness when evaluating a patient with suspected vestibular migraine. Diagnostic confusion with Meniere disease is common, particularly if episodes of vestibular migraine are accompanied by tinnitus, muffled hearing, or ear pressure. The presence of low frequency hearing loss favors the diagnosis of Meniere disease. An aura of brainstem symptoms (eg, diplopia, dysarthria) combined with vestibular complaints is suggestive of basilar migraine.

Multiple sclerosis plaques that affect central vestibular structures may cause recurrent episodes of vestibular symptoms, particularly during illness and with heat exposure (Uhthoff phenomenon). These attacks are not associated with migrainous or aural symptoms, and the demyelinated plaques may be visible on MRI.

For more on this topic, see Top 5 CNS Causes of Dizziness, on which this slideshow is based.

Dr Beh is Assistant Professor of Neurology, Director, Vestibular & Neuro-Visual Disorders Clinic, University of Texas Southwestern Medical Center at Dallas.