Vestibular Migraine: Symptoms, Diagnosis and Treatment

Vestibular migraine (VM) is a dizziness condition that causes repeated, unprovoked attacks of dizziness, imbalance, motion sensitivity, and sometimes headaches.
It is one of the most common causes of recurrent vertigo, but is frequently missed or misdiagnosed as Ménière’s disease, anxiety, “ear problems”, or simply “stress”.

VM affects an estimated 3% of the population, but up to 30–50% of people diagnosed with migraine experience vestibular symptoms at some point. This is one of the most common diagnosis of dizziness along with BPPV and vestibular weakness. Research shows it is more common in women and often begins in middle adulthood, although it can occur at any age—even in children.

What Are the Main Symptoms of Vestibular Migraine?

Symptoms vary between individuals and even from attack to attack, but common features include:

Vestibular symptoms

• Spinning vertigo
• Rocking / Swaying sensation
• Imbalance or unsteady gait
• Motion sensitivity (car, supermarket aisles, scrolling screens)

Sensory symptoms

• Sensitivity to light, sound, or smells
• Vision changes (blur, after-images, visual “snow”)

Headache symptoms

• Throbbing pain (but headache is not always present)
• Pain on one side of the head
• Worsening with physical activity

Cognitive / Emotional effects

• Brain fog
• Anxiety during or after attacks

Attacks can last minutes, hours, or days.

What Causes Vestibular Migraine?

The exact mechanism is complicated and still being studied, but involves abnormal processing in:

• The brain (brainstem and vestibular nuclei)
• Visual–vestibular pathways
• Pain modulation networks

Genetic predisposition and environmental triggers are involved.
Vestibular migraine is not a problem of the ear itself, despite the dizziness.

How is Vestibular Migraine Diagnosed?

Diagnosis is clinical. There is no single test that “proves” vestibular migraine. It is a diagnosis of exclusion, where a complete vestibular investigation is performed to rule out a significant vestibular weakness before relating the symptoms—including dizziness and balance problems—to the diagnosis of vestibular migraine.

Vestibular testing (VNG, vHIT, VEMP, audiometry) is often normal, but used to rule out:

• Ménière’s disease
• BPPV
• Vestibular neuritis
• Central pathologies

Lab tests and MRI are used when symptoms are atypical.

Common Triggers of Vestibular Migraine

Triggers are highly individual, but frequently reported ones include:

Diet

• Caffeine
• Alcohol (especially red wine)
• Aged cheese
• Processed meats
• MSG / Aspartame
• Fasting / irregular meals

Lifestyle

• Poor sleep
• Dehydration
• High stress
• Bright / Flickering lights
• Motion and busy visual environments

Hormonal

• Menstruation
• Hormone therapy changes

Sensory overload

• Loud noise
• Screen scrolling

Treatment Options for Vestibular Migraine

There is no particular cure just as general migraine, but most people improve with a combination of:

1. Lifestyle and Trigger Management

Often the most effective approach:

• Regular meals
• Adequate hydration
• Reduction of caffeine and alcohol
• Sleep routine
• Stress management

Not everyone needs a strict diet, but identifying personal triggers is crucial.

2. Preventive Medications

Used for frequent or severe attacks and prescribed by a medical doctor:

• Amitriptyline
• Nortriptyline
• Propranolol
• Topiramate
• Candesartan
• Venlafaxine

Response may take 6–12 weeks.

3. Acute Medications

To treat attacks, your medical team may prescribe:

• Triptans
• NSAIDs
• Antiemetics

Effectiveness varies.

4. Vestibular Rehabilitation Therapy (VRT)

Not “balance exercises” in a casual sense.

Useful for:

• Motion sensitivity
• Balance impairment
• Visual–vestibular mismatch

Evidence suggests Vestibular Rehabilitation Therapy (VRT) helps, especially when combined with migraine control.

5. Nutritional Supplements

Evidence is limited but some data supports:

• Magnesium
• Riboflavin (B2)
• CoQ10

Low risk, but take these only after consulting a doctor.

Prognosis- long term outcome of vestibular migraine 

Vestibular migraine is chronic but manageable.
Most patients achieve substantial improvement with a personalised plan.

The biggest risk factor for persistent symptoms?
Doing nothing and hoping it goes away.

Vestibular Migraine vs Ménière’s Disease

It is possible to have both conditions, which complicates diagnosis.

Other common overlaps

VM with persistent perceptual postural dizziness (PPPD) and BPPV
Data Credit: https://dizziness-and-balance.com/disorders/central/migraine/mav.html?JAVASCRIPT=ON

Scientific References

Bárány Society / ICHD

Lempert, T., & von Brevern, M. (2019). Vestibular migraine. Neurologic Clinics.
https://pubmed.ncbi.nlm.nih.gov/31563227/

Epidemiology & diagnosis

Formeister, E. J., Rizk, H. G., Kohn, M. A., & Sharon, J. D. (2018). The epidemiology of vestibular migraine: A population-based survey study. Otolaryngology–Head and Neck Surgery, 39(8), 1037–1044. https://doi.org/10.1097/MAO.0000000000001900 

Clinical aspects and pathophysiology

Furman, J. M., Marcus, D. A., & Balaban, C. D. (2013). Vestibular migraine: Clinical aspects and pathophysiology. The Lancet Neurology, 12(7), 706–715. https://doi.org/10.1016/S1474-4422(13)70107-8 

Treatment

Smyth, D., Britton, Z., Murdin, L., Arshad, Q., & Kaski, D. (2022). Vestibular migraine treatment: A comprehensive practical review. Brain, 145(11), 3741–3754. https://doi.org/10.1093/brain/awac264 

VRT

Whitney, S. L., Alghwiri, A. A., & Alghadir, A. (2016). An overview of vestibular rehabilitation. Handbook of Clinical Neurology, 137, 187–205. https://doi.org/10.1016/B978-0-444-63437-5.00013-3 

Dietary triggers

Hindiyeh, N. A., Zhang, N., Farrar, M., Banerjee, P., Lombard, L., & Aurora, S. K. (2020). The role of diet and nutrition in migraine triggers and treatment: A systematic literature review. Headache, 60(7), 1300–1316. https://doi.org/10.1111/head.13836 

Vestibular Migraine FAQ

Q.1. Is vestibular migraine dangerous?
No, but it is disruptive and disabling. Symptoms are real, not psychological.

Q.2. Do I need a brain scan?
Sometimes, especially if symptoms are new, sudden or atypical.

Q.3. Is it caused by anxiety?
No. Anxiety can worsen symptoms, but it does not cause them.

Q.4. Will I go deaf?
Unlikely. VM rarely causes permanent hearing loss.

Q.5. Does vestibular rehab help?
Yes, especially for motion sensitivity and imbalance.

Q.6. Do I need medication?
Not always. Lifestyle strategy alone works for many patients.

Q.7. Is caffeine bad?
For many people, yes—although not universally.

Q.8. Can children get it?
Yes, but often misdiagnosed as “motion sickness”.

Key Takeaway

Vestibular migraine is common, real, and treatable.
A combination of lifestyle modification, medical treatment, and vestibular rehabilitation is usually effective.

The goal is not perfection—just control good enough to get your life back.