Thirty percent of those diagnosed with vestibular migraine may present without history of headache [19]. Common complaints include acute episodes of vertigo lasting seconds to days, dizziness, imbalance, and spatial disorientation. Other symptoms may include lightheadedness, swimming sensation, heavy headedness, a rising sensation, tingling sensation, a rocking sensation, excessive motion sickness susceptibility; additionally, transient fluctuating hearing loss, aural fullness, tinnitus, and mild sensorineural hearing loss on audiogram are not uncommon. To define vertigo, one explains a sensation of motion when no motion is taking place or an altered sensation with normal motion. In a vestibular migraine, the sensation can oft be described as a "to-and-fro" sensation, and this can complicate diagnosis. Based on the variable duration, this disease can mimic other causes of vertigo. Vertigo and headache do not always present synchronously, in fact, it is rare for both symptoms to present simultaneously. There does not seem to be a consistent pattern of vestibular symptoms during headache presentation [3][15][20].

A vestibular migraine does not seem to go away. Episodes can be associated with women’s menstrual cycles. Studies have shown that nearly 50% of those diagnosed with probable vestibular migraine progress to definite a vestibular migraine according to the previously mentioned Neuheuser criteria. Another study showed that nearly 30% experienced increased frequency of attacks over a 9-year observation period, although nearly 50% experienced a reduced frequency of attacks. Nearly 90% of vestibular migraineurs still report vertiginous attacks after nine years. Additionally, cochlear complaints such as aural fullness, tinnitus and/or hearing loss during vertigo spells seem to become more common as time progresses [12].

A thorough history is imperative as there are no pathognomonic imaging studies or available testing consistent with a vestibular migraine. Despite this, there are nonspecific findings noted with certain studies. One such example comes with magnetic resonance imaging (MRI). MRI has shown an associated finding consistent with a general migraine. White matter hyperintensities are four times more likely in this group as compared to age and gender-matched controls [21]. Some functional neuroimaging lends some light on general migraine pathophysiology; however, few such reports are available regarding a vestibular migraine and may be an area of future exploration and discovery.

Vestibular testing and neurotologic exams typically yield nondiagnostic abnormalities in those with isolated probable or definite vestibular migraine. It must be recognized, that if an individual has Meniere syndrome or BPPV association, they are more likely to have abnormal testing [16].

Another study has shown an increased incidence of unilateral canal paresis on caloric testing and vestibular hyporesponsiveness or hyperresponsiveness in vestibular migraine patients [12]. One study suggests abnormal sacculocollic pathway (cervical vestibular evoked myogenic potentials (cVEMP)) and normal ocular VEMP (oVEMP) findings in a vestibular migraine compared to healthy controls; however, these findings have not been duplicated [22]. These findings are not unique to a vestibular migraine.

Current management of a vestibular migraine consists of conventional migraine management as there is currently no accepted specific treatment for this disease [17][22]. Additionally, convincing a patient of the diagnosis can prove difficult and lead to a delay in treatment or absence of treatment. This is understandable based on the fact that vertiginous symptoms are often asynchronous with a headache and maybe a difficult connection for the practitioner or patient to grasp [23].

Sargent’s experience suggests that triptan therapy is rarely of benefit in the acute treatment of a vestibular migraine [3] despite small reports suggesting modest benefit in acute vertigo attacks [24] [25]. Triptans and calcium-channel-blocking medications have proven ineffective in shortening aura or preventing headaches in general migraine [23]; however, they have not been tested in vestibular migraine. Thus, for acute vestibular migraine only antiemetic and antivertigo therapies are currently recommended [3].

Current recommendations for vestibular migraine prevention include lifestyle changes such as avoidance of dietary, behavioral or sleep hygiene triggers [25]. In one retrospective study, caffeine cessation was associated with symptomatic improvement in 15% of the vestibular migraine population tested. This reduction in symptomatology was incomplete, however, and many required further medical therapy. From this study, 75% of those with a vestibular migraine experienced ample relief from lifestyle changes in addition to treatment with nortriptyline or topiramate and did not require further treatment. Nortriptyline gave relief in 46% while topiramate provided relief in 25% in this retrospective study [26][23]. In a separate prospective study, topiramate (50 to 100 mg per day) was shown to reduce the frequency and severity of vertigo and headaches [27].

A 2017 randomized controlled trial by Liu, et al. demonstrated the efficacy and safety of venlafaxine, flunarizine, and valproic acid in the prophylaxis of VM. Each treatment demonstrated unique treatment properties such as venlafaxine which showed an advantage in the treatment of emotional symptoms. Venlafaxine and valproic acid also were shown to be preferable to flunarizine in decreasing the frequency of vertiginous attacks. Valproic acid seemed to be less effective than venlafaxine and flunarizine in decreasing vertigo severity [28].

The American Headache Society, American Academy of Neurology recommend the following therapies as possibilities for an episodic migraine: butterbur, divalproate, metoprolol, propranolol, timolol, and topiramate [29]. Aside from topiramate, none of these have been evaluated for the treatment of a vestibular migraine specifically; however, it seems that one could consider these as potential treatment options. Other possibilities include amitriptyline and calcium channel blockers [24]. One could consider other existing comorbidities in conjunct with a vestibular migraine and tailor therapies to treat both or multiple illnesses, for example, nortriptyline for concomitant anxiety, topiramate or propranolol for associated headaches/hypertension).

Physiotherapy may play a role in treating some of the associated sequelae of vestibular migraine which include anxiety, visual dependence, and/or loss of confidence [23].

Those with interictal symptoms of imbalance could consider vestibular rehabilitation therapy as a potential treatment modality [30].

Currently, no surgical management is recommended for vestibular migraine and may result in worsening of illness is associated with Meniere syndrome (Wise SR & Sargent EW; presentation 2013).

Meniere syndrome and BPPV were discussed previously.

It is anticipated that nearly 50% of those with childhood vertigo are related to a migraine. Benign paroxysmal vertigo of childhood is the most common cause of vertigo between the years of 2 and 6 with a prevalence estimated at 2.6% between the ages of 5 and 15 [31]. This typically presents with seconds to minutes of vertigo/dizziness, nystagmus, postural imbalance, nausea or vomiting with the return to baseline between episodes. Children may outgrow this condition, as many are relieved from its burden after their sixth birthday.

Chronic subjective dizziness (CSD) is an entity that includes chronic unsteadiness or dizziness without vertigo. Additionally, it presents with hypersensitivity to motion stimuli, poor tolerance of visual stimuli or precision visual tasks. This condition must last three or more months to make the diagnosis. It has been found that CSD often coexists with other recurrent vertigo illnesses [32].

The following diagnoses commonly replace a vestibular migraine when the patient is followed for an extended period: Meniere syndrome, benign paroxysmal positional vertigo, psychogenic dizziness, spinocerebellar ataxia. The following must be ruled out before making the diagnosis: episodic ataxia type 2 and transient ischemic attacks [3].

No studies have been discovered that show any prognostic variables associated with vestibular migraine.

Clinical experience has shown varying levels of disability and responsiveness to treatments amongst the vestibular migraine population.

No operative therapy is currently recommended for a vestibular migraine and may actually worsen clinical state (Wise SR & Sargent EW at presentation given 2013).

Physiotherapy may play a role in treating some of the associated sequelae of a vestibular migraine which include anxiety, visual dependence, loss of confidence [23].

Neurotologic and/or neurology evaluation seems to be a reasonable recommendation.

Convincing a patient of the diagnosis of a vestibular migraine can prove difficult and lead to delay in treatment or absence of treatment. This is understandable based on the fact that vertiginous symptoms are often asynchronous with a headache and may be a difficult connection for the practitioner or patient to grasp [23].

A vestibular migraine is an elusive diagnosis with variable presentation and without pathognomonic testing despite significant associated morbidity

Familiarity with recently accepted Barany Society and the International Headache Society diagnostic criteria is important to make a diagnosis. See below:

• At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 minutes to 72 hours 
• Current or previous history of a migraine with or without aura according to the ICHD classification
• One or more migraine features with at least 50% of vestibular episodes: headache with at least 2 of the following characteristics: one-sided location, pulsating quality, moderate or severe pain intensity, or aggravation by routine physical activity; photophobia or phonophobia; visual aura
• Not better accounted for by another vestibular or ICHD diagnosis

A vestibular migraine can present at any age, although middle-aged women are most commonly affected

One theory exists that a vestibular migraine may be caused by vestibular end-organ disease; therefore, regular patient monitoring is merited to evaluate for possible contributing morbidity

A vestibular migraine may be associated with other illnesses such as Meniere syndrome or BPPV. The verdict is currently out regarding the chronology of events/triggers. Do Meniere attacks trigger a vestibular migraine, or does a vestibular migraine give rise to Meniere syndrome features?

The diagnosis and management of vestibular migraine is complex and best done with an interprofessional team. There are many treatments for vestibular migraine but there is no specific treatment that works in everyone. Current treatment options include lifestyle changes such as caffeine omission, avoidance of known dietary, behavioral or sleep hygiene triggers. Prophylactic medications such as topiramate, nortriptyline, propranolol may provide some benefit despite few controlled studies on the matter. Vestibular rehabilitation may play a role. Treatment of associated anxiety is a necessity.

The prognosis for these patients remains unknown but anecdotal reports indicate that recurrences are common.