What Is A Vestibular Migraine?
Vestibular Migraine
Vestibular migraine is one of the most common causes of repeated, unexplained episodes of dizziness and vertigo. Most people think of migraine as a moderate to severe pounding or throbbing headache, but a vestibular migraine may or may not include headache. Instead, it usually causes vestibular symptoms such as dizziness, vertigo, motion sensitivity, unsteadiness and loss of balance (1).
Because vestibular migraine can look like other serious conditions, call 911 if you have sudden severe dizziness or headache along with weakness, numbness, trouble speaking, double vision, facial drooping or trouble walking. These can be signs of a stroke.
How Common Is Vestibular Migraine?
According to the Migraine Research Foundation, about 1 in 4 U.S. households includes someone with migraine, and migraine is among the most common and most disabling illnesses in the world (2). Vestibular migraine affects about 1% of people, including children, and it is more common in women than in men (3).
What Causes Vestibular Migraine?
Vestibular migraine likely results from a mix of genetic and environmental factors. Migraine often runs in families, and it may also begin after a major change such as a traumatic brain injury.
For many years, migraine was explained mainly by changes in blood vessels. In this model, when nerve cells in the brain’s outer layer, the cortex, fire rapidly, they signal nearby blood vessels to increase blood flow. Reflexes from the brainstem also help control blood flow to the cortex. If these systems don’t keep up, nerve cells may not get enough oxygen and glucose for how hard they’re working. This is thought to contribute to a wave of reduced brain activity called cortical spreading depression, which can cause aura symptoms.
In classic migraine, auras can look like wavy lines or flashing lights. In vestibular migraine, aura symptoms can feel like movement or imbalance. Spreading depression releases chemicals that irritate pain-sensing nerves around blood vessels. When the blood vessels then widen, those sensitized nerves respond to the stretch of each pulse, creating migraine’s typical throbbing pain.
Current research suggests this blood vessel model is too simple, and that brain chemistry and inflammation in the nervous system may play a bigger role than blood vessel size (4).
The causes of vestibular migraine may vary from person to person. Research has linked changes in brain chemicals such as serotonin (5) and hormones such as estrogen (6) to the development of migraine.
What Are the Symptoms of Vestibular Migraine?
Symptoms of vestibular migraine may include any or all of the following:
Dizziness lasting more than a few minutes
Nausea and vomiting
Loss of balance
Strong motion sensitivity (feeling sick when moving your head, eyes or body)
Feeling disoriented or confused
Feeling unsteady, like you’re rocking on a boat
Sensitivity to sound
Sensitivity to light
Lightheadedness
Sensitivity to pressure changes, such as during flying
Ringing in the ears
A feeling of fullness or pressure in the ears
Symptoms usually last from a few minutes to 72 hours. Triggers for vestibular migraine are often the same as for other migraines, including stress, lack of sleep, dehydration, weather or air pressure changes, glaring or flickering lights, and menstrual cycles. Some foods have also been studied as possible triggers, including chocolate, red wine, aged cheeses, MSG, processed meats and caffeinated drinks (7). Many people with vestibular migraine have a personal history of motion sickness or migraine, sometimes going back to childhood.
How Does Vestibular Migraine Affect Your Life?
Migraine is a major cause of disability and lost productivity. According to the Migraine Research Foundation, more than 90% of people with migraine can’t work or function normally during an attack, and more than 20% of people with chronic migraine are disabled. Migraine-related healthcare costs and lost productivity may total as much as $36 billion a year in the United States, and healthcare costs for a family with someone who has migraine are about 70% higher than for other families (2). Overusing pain medication is a common reason occasional migraines become chronic, so talk with your doctor if you’re taking pain relievers often.
Migraine and vestibular symptoms can also take a heavy toll on mental health. Chronic headaches are closely linked with depression and anxiety (8). Migraine is also linked with poor sleep, which can feed a cycle of low mood, more sleep problems and more headaches (9).
What Happens in the Brain With Vestibular Migraine?
Cortical spreading depression, which is thought to cause migraine aura, is believed to play a role in vestibular migraine, especially in people with short vertigo attacks. If spreading depression reaches the parts of the cortex that process balance, mainly the posterior insula and the temporoparietal junction, it may cause vestibular symptoms (10).
Brain chemicals also seem to be important. Several chemicals involved in migraine, including calcitonin gene-related peptide (CGRP), serotonin, norepinephrine and dopamine, also affect how the inner ear and its brain pathways work. Changes in these chemicals may help explain both migraine and the specific symptoms of vestibular migraine (11).
Changes in the trigeminal pain system and a process called central sensitization also appear to play an important role. Most people think of pain like an on-off switch: either something hurts and something is wrong, or it doesn’t hurt and everything is fine. But that’s not really how your pain system works. A better comparison is the strength-tester game at a carnival. You swing the hammer, the puck shoots up, and if you hit hard enough, it rings the bell at the top. Your pain receptors are the hammer, and your pain threshold is the height of the bell. Ideally, the hammer hits softly and the bell sits high, so it takes a lot to ring it.
Pain signals from your head and face travel through your trigeminal nerve (12), which also carries pain signals from the blood vessels and membranes surrounding the brain. When pain receptors are pressed on or irritated by inflammation, they send signals to a group of nerve cells in the brainstem called the spinal trigeminal nucleus (13). This is the striker in our carnival game. It constantly receives some background input from the trigeminal nerve, from movement, from chemical byproducts and more. So the brain has pathways that send signals down to calm the trigeminal nucleus, making sure normal background activity doesn’t register as pain. That’s the height of the bell.
The trigeminal system doesn’t only receive input from your head, face and brain. It also receives pain input from the top three segments of your neck, including the area at the base of your skull. If there’s enough pain input from your upper neck, the bell can start to ring and you feel a headache.
If that input is strong enough, pain can spread through the trigeminal system. You may feel pain not just at the base of your skull, but behind your eyes, in your forehead, in your jaw and in other areas served by this nerve. This is a kind of crosstalk, much like how a heart attack can cause pain in the left arm even though nothing is wrong with the arm. Many of the pain receptors around the brain surround blood vessels, so when the trigeminal system is highly activated, you may feel throbbing pain with every heartbeat. This may be another driver of migraine pain.
Your pain system works like the rest of your nervous system: the more it’s used, the better it gets at its job. Unfortunately, that means if the bell keeps ringing for a long time, the bell gets lower, and it takes less to trigger a migraine.
When the trigeminal system is activated, it can start a cycle of inflammation in the nervous system that spreads to other areas, lowering the bell even further. When the bell gets very low, things that shouldn’t hurt, like light, sound, a soft touch or movement, can become painful. This is called allodynia. Trigeminal nerve fibers also supply blood vessels in the inner ear, where the balance and hearing systems are located, which may help explain why vestibular migraine can cause dizziness and hearing symptoms. Researchers believe vestibular migraine involves the brain and brainstem systems that normally regulate trigeminal input (14), and that connections between the brainstem’s balance centers and its pain-control centers may be part of the cause (5).
How Is Vestibular Migraine Diagnosed?
Vestibular migraine is diagnosed by a healthcare provider based on your history and a physical and neurological exam. There’s no single test for it. International diagnostic criteria generally include:
Repeated episodes of moderate to severe vestibular symptoms, usually lasting from 5 minutes to 72 hours.
A current or past history of migraine.
Migraine features, such as headache, sensitivity to light or sound, or visual aura, during at least half of the episodes.
Other causes ruled out by appropriate testing.
MRI or CT scans are often used to rule out other problems, such as a tumor or bleeding in the brain, but they can’t show the changes that cause migraine (15).
How Is Vestibular Migraine Usually Treated?
Many types of medications are used to prevent and treat migraine, and vestibular rehabilitation and lifestyle changes are also commonly recommended. Many people improve with treatment, but some continue to have symptoms. Many people spend years searching for answers, seeing many providers and trying many treatments. Their lives can become very restricted as they try to avoid foods and other triggers. Millions of people live with long-term effects of vestibular migraine, and some have nearly given up hope (15).
We created the NeuroRescue Program for people like you, with the goal of addressing the neurological factors that may be contributing to your symptoms, so you can get back to doing the things you love.
How the NeuroRescue Program Can Help
Our care is designed to work alongside your physician, neurologist and other providers, never in place of them. Please don’t change or stop any medication without talking with your prescriber.
We evaluate the many factors that may be contributing to your vestibular migraine. This includes the muscles, joints, ligaments and nerves of your neck and jaw, the nervous system pathways that control them, and the brain and brainstem systems that normally calm pain and keep your eye movements stable and accurate. We bring all of this together into a personal plan aimed at the factors driving your symptoms.
One of the brain’s most important jobs is figuring out where you are in the world. It uses your inner ear to sense where your head is in relation to gravity and how it’s moving, your muscles and joints to sense where your body is and what it’s doing, and your eyes to sense where you are in relation to everything around you. Your brain combines all of this into a picture of where you are, so you can respond to the world around you.
Vestibular migraine is rarely just a problem with the eyes, the inner ear or the neck alone. It often involves how well these systems work together. When they don’t integrate well, some pathways may fire too much and others too little, which may contribute to symptoms. That’s why we look at all of them together.
Eye movements can be affected in vestibular migraine. Studies have found abnormal eye movements called nystagmus during vestibular migraine attacks, suggesting brainstem involvement (16). Saccades, the fast eye movements you use to shift your gaze between targets, have also been found to be affected in migraine, with patterns suggesting reduced control in people with more severe migraine (17). Other saccade findings suggest the cerebellum, which researchers now think may be involved in migraine, may also play a role (18).
Research has also found changes in brain areas that process balance and pain in vestibular migraine. Studies have found reduced gray matter in several areas of the brain involved in pain and balance processing, and a smaller prefrontal cortex has been linked to more severe headaches (19). The structure of balance-processing areas of the cortex has also been found to be different in vestibular migraine (20), which may contribute to problems with balance and thinking (21). Vestibular rehabilitation has been shown in studies to help reduce how often vestibular migraine attacks happen and how intense they are (22), and it is often a core part of our care.
Depending on your needs and test results, your program may include training for specific eye movements that can be affected in migraine (17); exercises for inner ear reflexes that affect brainstem function (23); care for the muscles and joints of your neck and jaw, including chiropractic adjustments when appropriate; electrical stimulation (24); light therapy, also called photobiomodulation (25); and exercises in a virtual reality environment (26). Transcranial magnetic stimulation (TMS) has been studied for migraine (27). At our clinic, TMS is provided by our psychiatric mental health nurse practitioner, who will evaluate whether it may be appropriate for you. Some programs include mild hyperbaric therapy as a structured recovery option between more demanding therapy sessions. The therapies we recommend are always chosen based on your testing and exam findings.
How the NeuroRescue Program Works
Your NeuroRescue Program begins with your Discovery Day. We start with a detailed history of your condition and your life on a timeline. This helps us understand the factors that may have contributed to where you are now, and identify related conditions that may be making it harder to move forward.
We measure how your visual, vestibular and balance systems are working through computerized analysis of your eye movements, inner ear reflexes and balance under different conditions. Our testing includes videonystagmography and saccadometry to measure several types of eye movements, the video head impulse test to measure inner ear reflexes, and CAPS computerized posturography to assess your balance under different sensory conditions. We also use NeuroSensoryMotor Integration testing to evaluate hand-eye coordination and cognition, and Virtualis testing to assess dynamic eye tracking and your perception of vertical in a virtual reality environment.
We combine this with a thorough physical and neurological exam of your sensory, motor, autonomic and cognitive systems. We also review any relevant lab work, imaging and prior testing, and integrate it with our findings.
Together, this helps us understand which parts of your nervous system are working well, which are struggling, and how quickly they tire. We use that information to design your personal NeuroRescue Program, aimed at improving function in the systems that need support and helping them work together. Our testing also helps us decide when to push and when to let you rest.
Our goal is to help reduce how often and how severely your attacks happen, so you can feel steadier, more confident and more like yourself again.
Your Next Step
Living with vestibular migraine can be exhausting and isolating, but you don’t have to keep searching alone. To find out if the NeuroRescue Program is right for you, contact one of our patient care coordinators to schedule your Discovery Day.
It’s never too late to take the next step.
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