Timothy C. Hain, MD •Page last modified: October 24, 2021
You may also be interested in our many other pages on migraine on this site
Dizziness and headache are individually very common human conditions and their combination is also a common symptom complex. Diagnostically, one must determine whether the dizziness and headaches are independent or related to each other, and in particular, whether they are a manifestation of migraine. Here we will review the association between vertigo and migraine. This subject has also been reviewed by Reploeg and Goebel (2002) as well as Radke et al (2002).
|The forest of migraine and the tree of MAV|
The above reflects population data.
|MAV in our practice in Chicago mainly affects women between the ages of 50-60|
Migraine is one of the major causes of vertigo (with BPPV being the only one causing more).
About 14% of the adult population of the United States has migraine. The distribution differs between male and females. At all ages, about 5% of men have migraine (Stewart, 1994; Lipton et al, 2002). Women of childbearing age have a much higher prevalence, jumping up to roughly 10% at the onset of menstruation, and increasing to nearly 30% at the peak age of 35 years. At menopause, rates of migraine abruptly decline in women back to roughly 10%. The genetics of migraine is usually polygenetic with multiple genes contributing a little risk. This implies that perhaps we are dealing with a collection of illnesses, rather than a single one.
The figure above shows the distribution of migraine with dizziness in a subset of patients from the dizziness practice of the author. Although the populations being drawn from is different, and in particular includes very few children, it illustrates that migraine with dizziness is most commonly encountered in persons between 40 and 70, and that the female:male ratio is about 3:1.
Migraine headaches are often misdiagnosed by patients themselves as sinus headaches. Schreiber suggested that 88% of 2991 patients who had diagnosed themselves as having sinus headache, actually had migraine (Schreiber et al, 2004).
Migraine occurs frequently with several other causes of dizziness. The prevalence of migraine (13-14%) is hugely higher than that of Meniere's disease, which occurs in only 0.05% (1/2000) of the US population (Wladislavosky-Waserman et al, 1984). The prevalence of MAV (about 1%) is also far higher than Meniere's.
In a small study of persons with Menieres disease, the prevalence of Migraine was about 50%, compared with a figure of about 25% in the non-Meniere's population (Radke et al, 2002). This is shown on the diagram above, where there is an overlap between Meniere's disease and Migraine. Our clinic experience is roughly comparable, and we have seen far more patients than reported in the majority of these studies.
Other studies have shown different results however. There have also been recent studies showing that there is a higher frequency of BPPV in persons with Migraine, as well as vice versa (Ishiyama et al, 2000; Uneri 2004), and about half of persons with BPPV onset before the age of 50 meet criteria for migraine. Occasionally, of course, patients with migraine will have other disorders such as brain tumors. Go HERE to see an example of this rare situation.
|Table 1: Patients with Migraine having Vertigo|
|Percent of migraine patients with vertigo||Comment||Authors|
|26.5 %||Unsolicited migraine (n=200)||Kayan and Hood (1984)|
|33 %||Selby and Lance (1960)|
|42 %||Migraine with aura||Kuritzky et al (1981)|
In practices focused on treating migraine, 27-42 % of patients report episodic vertigo (See table 1). A large number (about 36%) of these patients experienced vertigo during headache-free periods. The remainder experienced vertigo either just before or during the headache. The incidence of vertigo during the headache period was higher in patients with aura as opposed to in those without aura. Akdal et al (2013) reported on 5000 of his own patients and found that about 25% of migraine patients had vertigo or dizziness, while only about 2.9% of patients that he diagnosed as tension headache, had vertigo or dizziness (Akdal et al, 2013). Although impressive, this is hardly a blinded study and one wonders if perhaps dizziness/vertigo contributed to making a diagnosis of migraine.
In practices focused on treating vertigo, 16-32% of patients have migraine (Savundra et al, 1997). The prevalence of migraine in the general population is roughly 13-14% (Stewart et al, 1994). The prevalance of migraine with vertigo in Germany has recently reported to be 1% (Neuhauser, Radtke et al. 2006). This seems a very low to us, perhaps because of the narrow criteria used in this study -- 3% seems a little more likely. In any case, it seems reasonable to conclude that there is an immense amount of migrainous vertigo, and that migrainous vertigo is among the most common causes of vertigo in the general population (BPPV is also quite common).
|Table 2: Patients with Migraine having Motion Sickness|
|Percent of migraine patients with motion sickness||Comment||Authors|
|45%||Children (60)||Barabas et al (1983)|
|50.7%||Unselected||Kayan and Hood (1984)|
Motion sickness is a common migraine accompaniment. Most studies report about 50% of patients with migraine have motion sickness, compared to about 5-20% for control groups.
Syncope can also accompany migraine, and this offers another entirely separate mechanism. In migraine, hypotension is likely hormonal, and is attributed mainly to vasopressin (Gupta, 1997).
|Fortification spectra, as might be seen in Migraine with aura.||Scotoma with aspects of a fortification.|
There has also long been noted a close association between Meniere's disease and Migraine.
MAV is one of a group of conditions that encompasses many dizzy patients (including Meniere's disease, chronic subjective dizziness, cervical vertigo), that are diagnosed from the pattern of symptoms rather than from a "blood test" or "X-ray". These type of conditions nearly always are at least somewhat controversial, and have proponents as well as detractors. They always have the clause "not better accounted for by ...", which means that they are "wastebasket" diagnoses. ''
The author of this page, Dr. Hain, based on 1000's of patient care experiences, uses the following simple criteria to assign the diagnosis of MAV.
- Headaches that reduce ability to carry out activities of daily living, either ongoing, or having a past history of migraine headaches (e.g. previous aura)
- No other reasonable explanation (i.e. wastebasket)
- Responds to a migraine medication
The International Headache Society, a self-appointed committee that considers itself the final authority on any condition that includes head pain, released their viewpoint (2013). This is a committee diagnosis, assigning the term "vestibular migraine". The implication of this term is that dizziness symptoms are "vestibular", i.e. related to the inner ear motion sensing apparatus. It would presumably then omit symptoms from, lets say, nystagmus (eye jumping) due to another source.
The IHS states in an appendix to their most recent diagnostic epic, called the "International Classification of Headache Disorders", or ICHD for short, state that the proper name for MAV is actually "Vestibular migraine", and that the terms "migraine-associated vertigo/dizziness", migraine-related vestibulopathy, and migrainous vertigo are "previously used terms". It seems to us that this is pretentious as the IHS cannot control what terms clinicians use for symptom collections like this.
Revelant to this topic, Abouzari et al, from the Univ of California concluded from a study of 427 patients, that "A large proportion of vertigo patients with migrainous features do not meet the ICHD criteria for VM. The differences between cohorts represent selection bias rather than meaningful features unique to the cohorts. As such, VM and MH with vestibular symptoms may exist on a spectrum of the same disease process and may warrant the same treatment protocols." (2020). We agree.
Well anyway, the criteria for "vestibular migraine" according to the IHS are:
A. At least 5 episodes fulfilling criteria C and D.
B. A current or past history of migraine with or without aura, using the IHS criteria. (The IHS criteria for migraine are equally cumbersome).
C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours. We find this criterion vague and also odd. What exactly is "moderate or severe" ? Why stop at 72 hours.
D. At least 50% of episodes are associated with at least one of the following 3 migrainous features:
1. headache with at least two of the following four characteristics:
- a). Unilateral location
- b). Pulsating quality.
- c) Moderate or severe intensity. This is vague.
- d) aggravation by routine physical activity. With very rare exceptions, all vestibular disorders are aggravated by head movement. They are generally unaffected by movement of things other than the head. This is a vague criterian.
As criteria 1c and 1d will always be met, this criterian boils down to 50% of episodes with a headache.
2. Photophobia AND phonophobia. We don't see why both are required. There are also many more sensory exaggerations that are left out here too.
3. Visual Aura. This is so rare as to be nearly useless
E. Not better accounted for by another ICHD-3 diagnosis or another vestibular disorder. This is the wastebasket clause. One would wonder what if you are dealing with another wastebasket syndrome -- such as CSD/PPPD or cervical vertigo.
Thus in essence, vestibular migraine is a subset of migraine associated vertigo, perhaps suitable for research studies. We think the criteria above are too cumbersome for clinical use - -and it is very reasonable to have one set of criteria for researchers who are interested in having extremely homogeneous populations, and another set for physicians who treat patients and are just trying to reduce pain and suffering. We applaud clinical studies of "migraine with vestibular symptoms" (e.g. Akdal et al, 2015), which we think are more useful to clinicians than the IHS criteria above.
There is no "test" for MAV that by itself, is specific and diagnostic. MAV, like psychiatric disorders, is usually diagnosed from the clinical pattern and by excluding alternatives. Logically, MAV should be detectable by identifying sensory hypersensitivity, in the context of dizziness and headache. However, so far little has been done to quantify sensory hypersensitivity(such as allodynia) in this population.
For the most part, ENG inner ear testing in MAV is normal, but a low-level positional nystagmus is very common (Polensek and Tusa, 2010). We agree with this -- especially pure upbeating supine. We also think there is more downbeating upright. Our guess is that these reflect genetic homogeneity in the migraine population.
Hearing testing in MAV is generally normal, but in our large MAV clinic population we sometimes see bilateral reduction of hearing at low frequencies. It resembles early Meniere's disease, but is bilateral.
On rotational chair testing, some authors report an increased VOR time constant (Jeong et al, 2010). We have not noticed this in our patients and we are dubious that this is true. The same authors also felt that there were higher than normal motion sensitivity susceptibility scores (seems reasonable), and often (21%), perverted head-shaking nystagmus, aka pHSn (we are dubious). As pHSN is unusual in other syndromes, finding it in a patient who otherwise fits the criteria for migraine is helpful.
Panichi et al (2015) suggested that imbalance provoked by optokinetic stimulation was greater in 15 patients with vestibular migraine. This is too low an 'n' to be of much help. It does seem reasonable however, given that patients with migraine complain more strongly about visual motion than non-migraine patients (our observations).
Migraine without aura (about 80%) and migraine with aura (about 15-20% -- perhaps less) are the most prevalent forms of migraine and also are the most prevalent types of migraine associated with dizziness and vertigo. Whether or not you designate someone with one of these variants depends largely on how carefully you ask about them and the age of the patient. There is quite a bit of noise related to visual symptoms as people age and they develop retinal disturbances. Symptoms include true vertigo with or without nausea and vomiting, and motion intolerance. Headache is usual but not required (see following). Auditory symptoms are common but usually bilateral (see following).
Sensory amplification is very common in migraine associated vertigo--
Hyperacusis (called phonophobia in this context) is common in migraine, but this may not differentiate it from inner ear disorders where a similar symptom is termed "hyperacusis". Sensitivity to light (photophobia) is also commonly present. Photophobia is not at all specific to migraine however, and can also accompany migraine imitators such as meningitis, and vertigo imitators such as Cogan's syndrome. Other sensory amplifications which are common in persons with migraine include allodynia (pain from stimuli of the head that are not painful in most people), sensitivity to weather changes, motion sensitivity, and medication sensitivity. Commonly persons with vestibular migraine are bothered by visual movement, such as scrolling a computer screen. This is a variant of visual vertigo.
When patients are examined acutely when vertiginous, there is usually minimal or no spontaneous nystagmus. This provides a differential feature from most peripheral vestibular syndromes. When nystagmus is present, it is often directed vertically (e.g. upbeating or downbeating). Vertically directed spontaneous nystagmus is unusual in other contexts, providing another differential point.
Timing. Cutrer and Baloh (1992) found a bimodal distribution of duration of vertigo with 31% of individuals having spells that typically lasted a few minutes to 2 hours and 49% having spells that lasted longer than 24 hours. Symptoms lasting months are possible (Waterson, 2004). Therefore by duration, these episodes could be confused with those due to BPPV, Menieres, or even vestibular neuritis.
Although migraines are usually episodic, they can be chronic too. Chronic migraine is the most severe of all migraine syndromes, with headaches averaging grater than 15 days/month. Each year, about 2.5% of those with episodic migraine develop chronic migraine (Manack et al, 2011). In our practice in Chicago, we encounter many persons who are extremely motion sensitive, have visual sensitivity, and sound sensitivity, lasting months ! These persons usually respond to migraine prevention medication. Similar patients with chronic symptoms, even with few headaches, have been reported by others (e.g. Waterson, 2004)
As in migraine, occasionally aura may occur without headache (acephalgic migraine), it also follows that vertigo may occur without headache. Examples are as follows:
Essentially a vertiginous migraine aura without headache, was described first by Slater (1979) but his observations have been confirmed by others (e.g. Lee et al, 2002; Cha et al, 2009). A more detailed discussion of BRV is found here.
Basilar Migraine, also known as Bickerstaff s syndrome(1961), consists of two or more symptoms from a rather long list (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields of both eyes, diplopia, bilateral paresthesias or paresis, decreased LOC) followed by a throbbing headache. Vertigo typically lasts between 5 minutes and one hour. In the authors practice, the typical patient is a woman of about 35 years of age, who attacks of vertigo combined with headache. The family history is often positive. In the differential are TIAs and paroxysmal vestibular disorders accompanied by headache. Some patients become dysarthric during attacks, slur their speech, and even become unconscious. This is extremely impairing.
Patients usually respond to the usual migraine prophylactic drugs. However, BAM can be extremely disabling and in persons who don't respond to the most common suspects, often one ends up trying a large assortment of prophylactics. In our worst patients, we think they do best on dopamine blockers (such as flunarazine). Often we also combine this with venlafaxine, propranolol, topiramate, and sometimes memantine. For abortives, we sometimes use cambia (diclofenac) or haloperidol drops. In other words, everything but the kitchen sink, usually including a dopamine blocker. This is due to the extreme severity of these patient's symptoms, which can resemble seizures or strokes. There is some overlap in these patients with hemiplegic migraine.
Auditory symptoms in BAM are rare compared to vestibular symptoms (Battista, 2004) but nevertheless there is good evidence that hearing loss and tinnitus do occur. Olsson (1991) in a study of 50 patients with basilar migraine (which is rare) documented a fluctuating low-tone sensorineural hearing loss in more than 50% of his patients, and about 50% of his patients noticed a change in hearing immediately prior to their migraine headaches. Virre and Baloh (1996) suggested that sudden hearing loss may also be caused by migraine. Hearing loss in migraine rarely progresses (Battista, 2004). Only minor changes of no significance are found in formal tests of auditory function in persons with migraine (Hamed et al, 2011).
Tinnitus is also common in migraine (Kayan and Hood, 1984; Olsson, 1991). Because the formal criteria for Menieres disease (audiometrically documented hearing loss (not fluctuation), episodic tinnitus and/or fullness, episodic vertigo) are a subset of the documented spectrum of basilar migraine, there is the possibility for diagnostic ambiguity (Harker, 1996). Boismier and Disher reported that 6% of 770 patients who presented with vertigo fell into an ambiguous diagnostic situation between Meniere's and Migraine (2002). When headache is not prominent, features such as bilateral hearing fluctuation (according to Harker (1996) auditory symptoms are rarely unilateral), family history of migraine and perimenstrual exacerbations are used to decide whether Menieres or migraine is the more likely diagnosis. Sometimes one just has to accept both as reasonable possibilities.
This is a disorder of uncertain origin, possibly migrainous. It's initials (BPV) are easily confused with those of Benign Paroxysmal Positional Vertigo (BPPV), but it is not caused by the same mechanisms. This disorder consists of spells of vertigo and disequlibrium without hearing loss or tinnitus (Basser, 1964). The majority of reported cases occur between 1 and 4 years of age, but this syndrome seems indistinguishable from benign recurrent vertigo (BRV, see following) in adults which is presently attributed to migraine, or so-called "vestibular Menieres", which is also attributed to migraine. The differential diagnosis includes Menieres disease, vestibular epilepsy, perilymphatic fistula, posterior fossa tumors, and psychogenic disorders.
Another confusing acronym that sounds somewhat like BPPV is "PPPD". When you tell a patient that they have "PPPD" it sounds to them somewhat like "BPPV", as all 4 letters have the "e" sound. PPPD actually is an acronym for a psychiatric diagnosis, "Persistent postural perceptive Dizziness".
This is a very disturbing disorder in which persons suddenly develop vomiting, generally without headache or hearing symptoms. It usually responds to migraine prevention medications. Vertigo is common (especially positional resembling lateral canal BPPV). It overlaps with migraine and Meniere's, but pretty much by definition there is no headache or hearing loss (if it did, it wouldn't be called cyclic vomiting -- it would be called migraine or Meniere's). See this page for more.
There has recently been a report of a familial vestibulopathy, confusingly called familial Benign Recurrent Vertigo (BRV) consisting of episodic vertigo with or without migraine headache. Presumably there are both familial and nonfamilial forms -- fBRV and BRV. The non-familial form is sometimes also called recurrent vestibular neuritis as well as vestibular Meniere's. In the current age of VHIT testing, it is easy to tell vestibular neuritis apart from BRV based on objective criteria. Vestibular Meniere's though is still waiting for a diagnostic test (perhaps MRI for hydrops).
Vestibular testing in the familial form can document profound bilateral vestibular loss. The familial syndrome responds to acetazolamide (Baloh et al, 1994). It is not associated with a mutation on the calcium channel gene (Oh et al, 2001). Also reported by Baloh and associates, a form exists with episodic vertigo and essential tremor. This form is also responsive to acetazolamide. (Baloh et al, 1996). Familial hemiplegic migraine has been linked to mutations in the calcium channel gene (Ophoff et al, 1996). French-Canadian intermittent ataxia syndrome also may present similarly. While no mutations have been identified in the common form of migraine, calcium channels could be functionally impaired by subtle gene changes such as polymorphisms.
Antiphospholipid antibodies. There are some reports that individuals with severe migraine headaches are more likely to have antiphospholipid antibodies. In the authors experience, these patients may present with transient monocular visual loss, and some also have fetal wastage and complicated migraines as well as a reticular rash on the legs. (Donders et al, 1998). Recent authors have suggested that the association of migraine with APA is not a valid one.
For treatment of migraine in general see this page. A flowchart is given here. Because of the possibility for serious injury associated with vertigo, prevention is the advised treatment for most types of MAV. Eliminating dietary triggers and prophylactic medication treatment are the modalities used most frequently. Patients are initially told to abstain from foods such as chocolate, strong cheese, alcohol (especially red wine) and MSG containing preparations (such as oyster sauce). We also suggest magnesium supplements (500 mg/day).
If this is not successful, after a month, patients are started on one of the following -- topiramate, verapamil, a long-acting beta-blocker such as long acting propranolol, or an antidepressant such as amitriptyline or venlafaxine depending on gender and medical situation. Verapamil and amitriptyline are particularly useful because of their anticholinergic properties may help control vertigo independently of whether they are useful for migraine per se. Venlafaxine is a very useful medication for vestibular migraine in particular (Salviz et al, 2015).
Adapted from lecture handout given for the seminar "Recent advances in the treatment of Dizziness", American Academy of Neurology, 1997 and "Migraine Vs Meniere's", at the American Academy of Otolaryngology meeting, 1999-2001.