"Vestibular migraine can occur without a headache, making diagnosis challenging." - Dr. Shin Beh

Migraine is NOT just a headache. It is a complex, chronic neurologic disorder affecting 15% of the population, with women three times more likely to be affected. It's the second leading cause of disability behind back pain and the second leading cause of vertigo behind Benign Paroxysmal Positional Vertigo (BPPV). You can learn more about BPPV in my blog post Vertigo is Not a Diagnosis: Benign Paroxysmal Positional Vertigo (BPPV) is a Common Cause of Vertigo.

A migraine attack causes changes in the brain, triggering inflammatory responses, release of hormones, which causes more inflammation. This affects the different regions that control sensory, motor, cognitive, emotional and autonomic functions. Migraine attacks, lasting 5 minutes to 72 hours, present with a throbbing headache, nausea, vomiting, and aura (dizziness, tingling of the face/extremities, visual changes like flashing/waving lights or zig zags lines, light, sound and smell sensitivity).

Vestibular migraine, CAN OCCUR WITHOUT HEADACHE, causing symptoms like vertigo, dizziness, imbalance, motion sensitivity, visual vertigo, nausea, headache, eye strain, sensitivity to light, sound, difficulty concentrating and ear ringing or fullness. This diagnosis was created in 2012 by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). Not many doctors, even neurologists and ENTs, are familiar with this diagnostic criteria and that is why it is challenging to get the right assessment and treatment plan. 

Vestibular Migraine Diagnostic Criteria

Formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS), this vestibular migraine diagnostic criteria has remained unchanged since 2012.

At least 5 episodes of vestibular symptoms and one of the 3 migrainous features below.

• A current or past history of Migraine without aura or Migraine with aura.

• Vestibular symptoms of moderate or severe intensity ("moderate" when they interfere with daily activities and "severe" when the activities cannot be continued), lasting between 5 minutes and 72 hours.

• At least half of all episodes have one of the 3 migrainous features.

1. Headache with at least two of the following four characteristics.

- unilateral location

- pulsating quality

- moderate or severe intensity

- aggravation by routine physical activity

2. Photophobia or phonophobia (sensitivity to light and sound)

3. Visual Aura

Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder. 

***Therefore, you can have vestibular migraine WITHOUT HEADACHE as a symptom!***

There is no special test to diagnose vestibular migraine but I recommend getting vestibular function testing with an audiologist through an ENT office as well as a hearing test (audiogram) to help rule out other vestibular disorders like BPPV, Meniere's Disease, vestibular neuritis, etc. Finding a practitioner who is familiar with the symptoms, knows what to listen for while you share your history and knows what questions to ask is key to getting the right diagnosis and treatment plan. 

If you feel you have “mysterious” symptoms that none of your doctors have been able to figure out, take a peek at this list, you might be suffering from vestibular migraine…

Possible Vestibular Migraine Symptoms (from Victory Over Vestibular Migraine by Shin Beh)

Vestibular:

• Unsteadiness

• Spinning

• Falling

• Floating

• Pulling in one direction

• Rocking, swaying

• Dizziness, disorientation, lightheadedness,” feeling off,” brain vibrating

• Positional vertigo: lying on back or side

• Head motion-induced vertigo

• Visually-induced vertigo: complex, busy, distorted, or moving visual stimuli 

Visual-Vestibular:

• Nystagmus

• Visual lag

• Movement-induced blur

Visual:

• Blurry vision

• Impaired depth perception

• Eye strain or fatigue

• Visual snow

• Double vision

• Visual trailing

Ear Symptoms:

• Ear pressure (fullness)

• Tinnitus (ringing)

• Muffled or loss of hearing 

• Rare: Unusual sensations inside ear (bubbling, pulsations, itching, tingling, pain, popping)

Migraine:

• Headache

• Light, sound, smell sensitivity

• Nausea and/or vomiting

Sensory:

• Numbness 

• Tingling

• Muscle weakness

• Difficulty speaking

Neuropsychiatric: 

• Brain fog 

• Fatigue

• Mood disturbances: depression, irritability, anxiety, panic

• Word finding difficulties

Autonomic:

• Diarrhea

• Sweating

• Feeling hot

• Hunger

• Loss of appetite

There is Hope!

It saddens me when my patients come for an evaluation with a diagnosis of vertigo, which by the way is only a symptom, NOT a diagnosis. They have been suffering with many of the above symptoms for years, have been seen by several doctors without any answers and made to feel crazy. Some can’t drive, consistently call in sick for work or have to go on disability, cancel social engagements and vacations, aren’t able to care for their children or manage their household. Vestibular migraine (and all vestibular disorders), is an invisible disorder. Outwardly, a person may seem fine physically and mentally, but vertigo and dizziness can be very isolating, causing anxiety, depression, fear of falling and fear that life won’t ever be normal again. If you feel this way, give yourself grace and know there is hope and help available for you. 

If you’ve found this information enlightening and if you think you may suffer from vestibular migraine, share with your doctor and ask to be seen by an ENT or neurologist who specializes in vestibular disorders. Check out Vestibular Disorders Association (VEDA) at vestibular.org to find a provider near you. If you live in the Bay Area in Northern California, Dr. Kristen Steenerson at Stanford Ear Institute and Dr. Michelle Inserra at Ears Associates are vestibular disorders specialists. If you suffer from classic migraine, Dr. Zepure Kouyoumdjian at South Valley Neurology comes highly recommended by my patients. And if you need help with your vestibular and balance symptoms, reach out to Balance Solutions Rehab for a free discovery call and to schedule an appointment.