Wiki Migraine

Vestibular migraines are a type of migraine that primarily affects balance and can cause significant dizziness or vertigo. Unlike typical migraines, where headache pain is the predominant symptom, vestibular migraines involve disturbances in the vestibular system, which controls balance and spatial orientation. This condition can be particularly debilitating, as the dizziness and balance issues may persist even when the headache is mild or absent. Understanding the symptoms, triggers, mechanisms, and treatment of vestibular migraines can help those affected manage this complex condition.

1. Symptoms of Vestibular Migraines

Vestibular migraines involve a range of symptoms that affect balance, coordination, and perception of movement. These symptoms can vary in intensity and duration, from mild unsteadiness to severe vertigo, and they may occur with or without the typical migraine headache.

1.1 Dizziness and Vertigo

The hallmark symptom of vestibular migraines is dizziness or vertigo. Vertigo is a sensation of spinning or whirling, either of oneself or the environment, and is often described as feeling off-balance or disoriented.

• Vertigo: A sensation of spinning, swaying, or tilting, even when stationary. The world may feel as though it’s moving or spinning around the individual.
• Dizziness: A feeling of lightheadedness or unsteadiness. This can make walking or standing difficult and may cause the person to feel as though they are going to fall.
• Duration: Vertigo and dizziness can last from a few seconds to several hours or even days. In some cases, the vertigo episodes may be short but frequent, while in others, the dizziness can be persistent and long-lasting.
• Worsening with movement: These symptoms often worsen with head movements, sudden changes in position, or when looking at moving objects.

1.2 Imbalance and Unsteadiness

People with vestibular migraines may experience difficulty maintaining their balance, making it hard to walk or perform tasks that require coordination.

• Ataxia: Difficulty walking or standing, often described as feeling “drunk” or as though the ground is shifting beneath them.
• Clumsiness: Increased likelihood of bumping into objects or losing balance while performing routine tasks.
• Gait instability: A wide-based, unsteady gait is common, especially during vertigo episodes.

1.3 Motion Sensitivity

Vestibular migraine sufferers often have heightened sensitivity to motion, both their own and external movements.

• Visual vertigo: Difficulty focusing or feeling dizzy when looking at moving objects, such as passing cars or scrolling on a screen.
• Sensitivity to self-motion: Simple movements like turning the head or shifting position can trigger dizziness or imbalance.
• Difficulty in busy environments: Crowded spaces with lots of visual stimuli, like grocery stores or shopping malls, can intensify the sense of disorientation or dizziness.

1.4 Headache

Although not always present, many people with vestibular migraines experience headache pain. When headaches occur, they are typically similar to those of other migraine types:

• Pain location: Often on one side of the head (unilateral) but can affect both sides. It is typically throbbing or pulsating.
• Associated symptoms: Nausea, vomiting, sensitivity to light (photophobia), and sound (phonophobia) are often present alongside the headache.
• Headache duration: Can last anywhere from a few hours to several days.

1.5 Nausea and Vomiting

Nausea is a common symptom during vestibular migraine attacks, and in severe cases, it can lead to vomiting.

• Related to dizziness: The sensation of vertigo or severe dizziness often triggers nausea, making it difficult to eat or drink.
• Gastrointestinal discomfort: Some people also experience bloating or general stomach discomfort during a vestibular migraine.

1.6 Visual Disturbances

Like other types of migraines, vestibular migraines can cause visual aura or disturbances, although this is less common.

• Visual aura: Flashing lights, blind spots, or zigzag patterns in the visual field, similar to other migraine auras.
• Blurry vision: Difficulty focusing or seeing clearly, which may exacerbate feelings of dizziness.

1.7 Confusion and Cognitive Impairment

During vestibular migraines, some people experience “brain fog” or cognitive difficulties.

• Mental fog: Difficulty concentrating or thinking clearly.
• Memory problems: Temporary forgetfulness or trouble recalling words.
• Slowed thinking: Mental processes may feel slower or more challenging during an attack.

1.8 Sensitivity to Sound and Light

Many people with vestibular migraines experience increased sensitivity to light (photophobia) and sound (phonophobia), even when headache pain is mild or absent.

• Photophobia: Bright lights can intensify the dizziness or vertigo, making it necessary to retreat to dark environments.
• Phonophobia: Loud or repetitive sounds may worsen dizziness or contribute to feelings of disorientation.

2. Triggers for Vestibular Migraines

Vestibular migraines can be triggered by various factors, many of which overlap with triggers for other types of migraines. Identifying and avoiding these triggers can help reduce the frequency and severity of vestibular migraine attacks.

2.1 Stress

Emotional stress is one of the most common triggers for migraines, including vestibular migraines. High levels of stress, anxiety, or sudden emotional shifts can lead to episodes of dizziness or vertigo.

• Stress management: Techniques like mindfulness, meditation, and yoga can help reduce stress-related triggers.

2.2 Hormonal Changes

Hormonal fluctuations, particularly in women, can trigger vestibular migraines. Changes in estrogen levels before menstruation, during pregnancy, or menopause are common triggers.

• Menstrual cycle: Vestibular migraines may coincide with the menstrual cycle, especially during the premenstrual or menstrual phases.

2.3 Dietary Triggers

Certain foods and drinks can trigger vestibular migraines. Common dietary triggers include:

• Caffeine: Excessive caffeine intake or caffeine withdrawal.
• Alcohol: Particularly red wine or beer.
• Aged cheeses and processed meats: These foods contain tyramine, a known migraine trigger.
• MSG and artificial sweeteners: Found in processed and fast foods.
• Dehydration: Not drinking enough water can also contribute to migraine attacks.

2.4 Sensory Overload

Vestibular migraine sufferers are particularly sensitive to sensory stimuli. Overstimulation of the senses, such as bright lights, loud noises, or strong smells, can trigger attacks.

• Flashing lights: Exposure to strobe lights, flickering screens, or bright sunlight.
• Crowded spaces: Environments with lots of visual or auditory stimuli can provoke dizziness and disorientation.

2.5 Sleep Disturbances

Both lack of sleep and changes in sleep patterns can trigger vestibular migraines.

• Sleep deprivation: Not getting enough sleep or irregular sleep schedules can increase the likelihood of a migraine attack.
• Oversleeping: Sleeping too much or changing sleep patterns can also trigger symptoms.

2.6 Weather Changes

Changes in weather, especially sudden shifts in barometric pressure, temperature, or humidity, are common migraine triggers.

• Storms and high humidity: Some individuals are sensitive to weather patterns like storms or drastic humidity changes, which can trigger vertigo or dizziness.

3. Mechanisms of Vestibular Migraines

The exact cause of vestibular migraines is not entirely understood, but they likely result from a combination of factors affecting both the brain’s processing of sensory input and the vestibular system, which controls balance.

3.1 Vestibular System Involvement

The vestibular system, which includes parts of the inner ear and brain responsible for balance and spatial orientation, is thought to be disrupted during vestibular migraines.

• Vestibular dysfunction: Abnormal signaling between the inner ear and brain can result in a mismatch between what the body feels and what the brain perceives, leading to dizziness, vertigo, and imbalance.
• Cerebellum involvement: The cerebellum, which helps control coordination and balance, may also be affected during vestibular migraines, contributing to the sense of unsteadiness or difficulty walking.

3.2 Migraine Pathways

Like other types of migraines, vestibular migraines may involve changes in neurotransmitters such as serotonin and fluctuations in blood flow to the brain.

• Cortical spreading depression: A wave of electrical activity that spreads across the brain’s cortex, often seen in migraines with aura, may also occur in vestibular migraines, disrupting normal sensory and vestibular processing.
• Serotonin imbalance: Abnormalities in serotonin regulation, which play a key role in other migraine types, may also influence vestibular symptoms by affecting the brain’s sensory pathways and vestibular system.

3.3 Overlap with Other Vestibular Disorders

Vestibular migraines can overlap with other balance disorders, such as Meniere’s disease and benign paroxysmal positional vertigo (BPPV). In some cases, patients may be misdiagnosed with these conditions, as the symptoms can be similar.

4. Diagnosis of Vestibular Migraines

Diagnosing vestibular migraines can be challenging because there is no specific test for the condition. Instead, diagnosis is based on clinical criteria, patient history, and ruling out other vestibular disorders. The diagnostic process often involves a combination of medical history, physical examination, and specialized tests.

4.1 Diagnostic Criteria (International Classification of Headache Disorders – ICHD-3)

The International Classification of Headache Disorders (ICHD-3) has established criteria for diagnosing vestibular migraines, which include:

• A history of migraines: The patient must have a history of migraines with or without aura.
• Vestibular symptoms: The patient must experience at least five episodes of moderate to severe vestibular symptoms, such as vertigo or dizziness, lasting 5 minutes to 72 hours.
• Migraine features: At least half of the vertigo or dizziness episodes must be accompanied by migraine features, such as headache, sensitivity to light or sound, or visual aura.
• No other causes: Other vestibular disorders, such as Meniere’s disease or BPPV, must be ruled out.

4.2 Vestibular Function Tests

To rule out other vestibular disorders and assess balance function, a neurologist or otolaryngologist may perform the following tests:

• Videonystagmography (VNG): Measures eye movements to assess the function of the inner ear and balance system.
• Rotary chair testing: Evaluates how the vestibular system responds to movement and changes in position.
• Posturography: Assesses balance and coordination by measuring body sway and reactions to movement.
• Hearing tests: Audiometric testing may be used to rule out conditions like Meniere’s disease, which often involves hearing loss.

5. Treatment of Vestibular Migraines

There is no cure for vestibular migraines, but treatment focuses on reducing the frequency of attacks, managing acute symptoms, and preventing future episodes. Treatment may include medications, lifestyle changes, and physical therapy.

5.1 Acute Treatment

During an acute vestibular migraine attack, the goal is to manage vertigo, dizziness, and headache symptoms.

• Triptans: These migraine-specific medications can be used to stop an acute migraine attack, especially if a headache is present. However, their effectiveness in treating vertigo is variable.
• Antiemetics: Medications like metoclopramide or prochlorperazine can help manage nausea and vomiting associated with vestibular migraines.
• Vestibular suppressants: Drugs like meclizine or benzodiazepines (e.g., diazepam) may help alleviate vertigo and dizziness during an attack.

5.2 Preventive Treatment

For people with frequent or severe vestibular migraines, preventive medications may be necessary to reduce the frequency of attacks.

• Calcium channel blockers: Verapamil is commonly used to prevent both vestibular and non-vestibular migraines.
• Beta-blockers: Propranolol is another option for reducing the frequency of migraines.
• Anticonvulsants: Medications like topiramate or valproate may be effective in preventing vestibular migraines.
• Antidepressants: Tricyclic antidepressants (e.g., amitriptyline) or selective serotonin reuptake inhibitors (SSRIs) can help manage both migraine symptoms and any associated anxiety or mood disorders.

5.3 Lifestyle and Dietary Modifications

• Dietary changes: Avoiding known triggers like caffeine, alcohol, and foods high in tyramine (e.g., aged cheese, processed meats) can help prevent attacks.
• Regular sleep patterns: Maintaining a consistent sleep schedule is crucial, as sleep disturbances are a common migraine trigger.
• Stress management: Techniques like yoga, meditation, or cognitive-behavioral therapy (CBT) can help reduce stress, which is a frequent vestibular migraine trigger.
• Hydration: Staying well-hydrated can help prevent migraines, as dehydration is a known trigger.

5.4 Vestibular Rehabilitation Therapy (VRT)

For patients with persistent imbalance or dizziness between attacks, vestibular rehabilitation therapy (VRT) may help improve balance and coordination. VRT involves exercises that retrain the brain to adapt to and compensate for dizziness and balance issues.

• Gaze stabilization: Exercises that help improve eye movement control and focus during head movements.
• Balance training: Exercises that improve steadiness and coordination, especially while walking or changing positions.

Conclusion

Vestibular migraines are a complex form of migraine that significantly affect balance and spatial orientation, causing dizziness, vertigo, and unsteadiness. These symptoms, which may occur with or without headache pain, can be severely disabling and often require a multifaceted approach to treatment. Identifying triggers, managing acute symptoms, and using preventive medications or vestibular rehabilitation therapy can help individuals manage this challenging condition and improve their quality of life.