Vestibular migraine is the most common cause of recurrent spontaneous vertigo in adults — more common than Meniere's disease, more common than vestibular neuritis. It is also one of the most under-recognised diagnoses in the dizziness world, primarily because many patients have no headache during their vestibular episodes.
Why It Matters
Population studies estimate vestibular migraine affects 1–3% of the general population and accounts for approximately 7–10% of all dizziness presentations to specialist clinics. The average diagnostic delay is 5–10 years.
The Bárány Society Diagnostic Criteria
Definite vestibular migraine requires:
- •At least 5 episodes of vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
- •A current or past history of migraine with or without aura
- •One or more migraine features during at least 50% of vestibular episodes
- •Not better accounted for by another diagnosis
Clinical insight: The absence of headache during a dizzy episode does NOT exclude vestibular migraine. Up to 50% of patients never have headache concurrent with their vestibular attacks.
Distinguishing From Other Conditions
Vestibular Migraine vs BPPV
- •VM: Dix-Hallpike nystagmus often absent or atypical, repositioning manoeuvres don't resolve symptoms, episodes are longer (hours) and more variable
- •BPPV: Upbeat-torsional nystagmus that fatigues and reverses, episodes brief (seconds), repositioning resolves
Vestibular Migraine vs Meniere's
- •Meniere's: Unilateral low-frequency SNHL, aural fullness, episodes typically 20 min to 12 hrs
- •VM: Hearing typically normal or transient changes only, broader episode range, stronger migraine history
The Role of Physiotherapy
VRT for vestibular migraine is about reducing central sensitisation and motion sensitivity — NOT aggressive habituation. Standard habituation-heavy VRT used for peripheral vestibular hypofunction can exacerbate vestibular migraine.
Components: low-intensity gaze stabilisation, balance training with graded visual complexity, gradual desensitisation to motion, trigger education, cervical management for the cervico-trigeminal pathway, and managing comorbid anxiety and avoidance.
Want to master this in practice?
The Dizziness Decoded series gives you a complete, hands-on framework for assessing and treating vestibular and dizziness conditions. Small groups of 12. Real practice. Real confidence.