If dizziness and headache come alternately or together, it may not be simple anemia or benign paroxysmal positional vertigo (BPPV), but rather ‘vestibular migraine.’ Vestibular migraine is a condition combining migraine and dizziness, and is one of the common causes of dizziness, yet it is frequently overlooked or misdiagnosed as BPPV or Ménière’s disease. This article first outlines the diagnostic criteria and differential diagnostic points, then provides self-management and prevention strategies you can implement.
Medical Background — What is Vestibular Migraine?
Vestibular migraine is a condition in which recurrent episodes of vertigo and migraine are associated with each other. It is defined as a separate diagnostic category in Appendix (A1.6.6) of the International Classification of Headache Disorders, Third Edition (ICHD-3) and the Bárány Society consensus criteria, with an estimated lifetime prevalence of approximately 1% in the general population. The prevalence is higher among patients with migraine.
During an attack, dizziness may manifest in various forms: not only rotatory vertigo (spinning sensation), but also swaying sensation, positional vertigo triggered by head movement, and dizziness accompanied by sensitivity to visual stimuli. Duration ranges from seconds to several days, but according to diagnostic criteria, meaningful attacks typically last 5 minutes to 72 hours. Headache does not necessarily accompany every dizziness attack, and light/sound sensitivity or visual aura may occur together.
Diagnosis and Differential Diagnosis — ICHD-3 Criteria
The key requirements for definite vestibular migraine according to Bárány Society and ICHD-3 Appendix criteria are as follows:
- Attacks of moderate or severe vestibular symptoms (rotatory or non-rotatory vertigo, positional vertigo, etc.) lasting 5 minutes to 72 hours, occurring at least 5 or more times.
- History of migraine without or with aura (meeting ICHD-3 criteria) in the past or present.
- At least one of the following migraine features accompanying 50% or more of dizziness attacks: unilateral, pulsating, moderate or greater intensity headache that worsens with routine activities, light or sound sensitivity, visual aura.
- Not better explained by another vestibular disorder or other ICHD-3 diagnosis.
Differential diagnosis is particularly important. Benign paroxysmal positional vertigo (BPPV) occurs briefly—within seconds to 1 minute—in specific head positions, without headache or light/sound sensitivity, and is confirmed by positional testing. Ménière’s disease is characterized by dizziness accompanied by fluctuating hearing loss, tinnitus, and ear fullness repeating for 20 minutes to 12 hours; if hearing loss is prominent, otolaryngologic evaluation is necessary. Additionally, dizziness first occurring in elderly patients, and dizziness accompanied by neurologic abnormalities (diplopia, dysarthria, unilateral weakness, severe gait disturbance) must exclude central causes such as stroke. Vestibular migraine is a ‘clinical diagnosis’ made on the basis of history and criteria after ruling out these conditions; there is currently no single confirmatory test or imaging finding.
Self-Management and Prevention — What You Can Do Today
From here onward, these are measures you can implement outside the clinic. It is helpful to remember that the main approach to vestibular migraine management is identical to migraine management.
Regular daily rhythm is the most fundamental. Since both sleep deprivation and excessive sleep can trigger attacks, sleep and wake at consistent times daily, do not skip meals, and drink sufficient water to avoid dehydration. Keeping a trigger diary for just 2–3 weeks helps identify your own triggers (sleep changes, stress, specific foods, caffeine, alcohol, menstrual cycle, barometric changes, etc.).
Maintain consistent caffeine intake. Both sudden cessation and excessive consumption can worsen dizziness and headache. If dizziness is sensitive to visual stimuli, take breaks from bright screens and visually complex environments; when an attack begins, rest in a quiet, dark place. This can be helpful.
If symptoms are frequent (roughly several times monthly) or disruptive to daily life, preventive treatment is considered. Along with medications used for migraine prevention (some beta-blockers, anticonvulsants, certain antidepressants, etc.), vestibular rehabilitation has evidence supporting balance recovery and reduction of dizziness sensitivity. Specific medication selection and dosage must be decided in consultation with your healthcare provider. Nutritional supplements such as magnesium, riboflavin (B2), and coenzyme Q10 are examined as adjunctive options in migraine prevention, but consultation with a specialist before use is recommended.
If You Experience These Warning Signs, Seek Medical Care Immediately
The following symptoms may suggest a more dangerous cause rather than vestibular migraine and warrant immediate medical attention:
- Sudden onset of severe dizziness or ‘thunderclap headache’ (reaching maximum intensity within seconds).
- Neurologic symptoms such as diplopia, dysarthria, unilateral limb weakness or sensory changes, severe gait imbalance.
- Newly developed unilateral hearing loss, progressively worsening tinnitus.
- Dizziness or headache first occurring after age 50, or dizziness clearly different from the patient’s prior pattern.
- Dizziness accompanied by high fever and neck stiffness, or decreased consciousness.
Conclusion
Vestibular migraine is surprisingly a common explanation for those who have suffered from ‘dizziness of unknown cause’ for a long time. If you have a migraine history and recurrent dizziness, simply recording the duration of attacks and accompanying symptoms and sharing this information at your consultation brings you one step closer to diagnosis. If dizziness repeats and destabilizes your daily life, consultation with a neurologist or headache specialist is recommended.
This article is intended to provide general medical information and does not substitute for diagnosis or treatment of individual patients. Accurate diagnosis and treatment must be discussed with your healthcare provider.