Vestibular Migraine: A Clinical Guide to Diagnosis and Management

Vestibular migraine is one of the most common causes of dizziness, affecting around 3% of the population.¹ Despite its prevalence, many patients remain undiagnosed and untreated due to a lack of awareness. Healthcare providers in neurology, otolaryngology, primary care, and emergency medicine should be equipped to diagnose and manage vestibular migraine to better serve this large patient population.

This article provides a comprehensive overview of vestibular migraine, including definition, diagnostic approach, challenges in clinical practice, and evidence-based management strategies.

What is Vestibular Migraine?

The pathophysiology of vestibular migraine is not fully understood but is best conceptualized as a migraine disorder with prominent vestibular network involvement.² Like migraine, it is likely caused by a combination of various genetic and environmental factors.

Vestibular migraine is characterized by recurrent attacks of dizziness with migraine features. Importantly, headache is not required for diagnosis, and migraine features may not accompany every attack.

The quality of dizziness varies widely and may include spinning vertigo, motion sensation, positional dizziness, lightheadedness, motion intolerance, unsteadiness, imbalance, or disequilibrium. Patients may report multiple symptom types. Recognizing this variability is essential, as vestibular migraine can mimic both central and peripheral vestibular disorders.

Diagnostic Criteria

Diagnosis is clinical and based on consensus criteria developed by the Bárány Society and the International Headache Society (IHS):³

1. At least five episodes of vestibular symptoms of moderate or severe intensity lasting 5 minutes to 72 hours.
2. Current or previous history of migraine with or without aura.
3. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours
4. Vestibular symptoms coinciding with migraine features during at least 50% of episodes (e.g., headache with two migraine features (unilateral location, pulsating quality, moderate or severe intensity, aggravation by routine physical activity) or photophobia/phonophobia or visual aura).
5. Symptoms not better accounted for by another vestibular or neurologic diagnosis.

Key Diagnostic Considerations

A small but important detail here is that migraine features (headache, sensory sensitivity, aura) do not always accompany episodes of dizziness. 

Patients may also present with probable vestibular migraine. As an example, a patient may have no personal history of migraine, but they have dizziness with migraine features. Alternatively, a patient may present with recurrent vestibular symptoms with no overt migraine features, but they may have a remote history of migraine, or find that attacks are precipitated by common migraine triggers. These patients may still benefit from migraine treatment.

Common Associated Features

Patients often present with additional symptoms, including:

• Brain fog 
• Fatigue
• Neck pain or muscle tension
• Autonomic symptoms (e.g., sweating, dry mouth, rhinorrhea, nasal congestion)
• Anxiety and depression 

Between attacks, there may be sensory integration dysfunction involving the visual, proprioceptive, and vestibular systems. This is referred to as Persistent Postural Perceptual Dizziness (PPPD), a separate but often accompanying diagnosis.

Clinical Evaluation

A detailed history is critical for accurate diagnosis:

• Characterize the onset, frequency, duration, and severity of episodes.
• Ask about any associated symptoms. True hearing loss that accompanies vertigo should raise suspicion for Meniere’s disease or other peripheral vestibular disorders. Bilateral tinnitus and aural fullness are common and do not necessarily indicate inner ear pathology. 
• Elicit migraine history carefully, including sensory sensitivity, aura, triggers, and family history of migraine. Do not forget migraine equivalents such as benign positional vertigo of childhood, abdominal migraine, optic migraine, or cyclic vomiting syndrome.

Physical Examination

The exam should include:

• Comprehensive neurologic exam (cranial nerves, gait, cerebellar testing, oculomotor function, tone, reflexes)
• Vestibular assessment (head impulse test, nystagmus evaluation, Dix-Hallpike maneuver)
• Otologic exam
• Orthostatic vital signs and cardiovascular screening

Diagnostic Testing

There is no definitive test for VM; the following are used to exclude alternative causes:

• Audiometry and vestibular function tests (VNG): helpful for identifying inner ear pathology. Abnormal findings do not rule out vestibular migraine. Low-grade positional nystagmus is common in migraine. 
• Neuroimaging (MRI/CT): Indicated when diagnostic criteria are not fully met, neurologic deficits are present, or red flag symptoms (e.g., aphasia, diplopia) are identified
• Laboratory studies: Guided by clinical context (e.g., CBC, BMP, TSH)

Differential Diagnosis and Diagnostic Challenges

Distinguishing vestibular migraine from other disorders is often difficult due to overlapping symptoms.

• Benign paroxysmal positional vertigo (BPPV) — Brief, positionally triggered vertigo with characteristic delayed, fatigable torsional nystagmus on Dix-Hallpike
• Ménière’s disease — Episodic prolonged vertigo with unilateral hearing loss, tinnitus, and aural fullness; it frequently coexists with vestibular migraine
• Persistent postural-perceptual dizziness (PPPD) — Chronic functional disorder often precipitated by vestibular migraine
• Transient ischemic attacks (TIA)/Central causes — Typically associated with additional neurologic deficits
• Vestibular neuritis/labyrinthitis — Acute loss of peripheral vestibular function resulting in up to several days of acute vertigo, while residual dizziness/imbalance can last for weeks to months. It is not typically recurrent.  

Since vestibular migraine can coexist with these disorders, clinicians must remain vigilant to overlapping pathology, especially when hearing loss or abnormal vestibular testing is present. 

Under-Recognition and Misdiagnosis

Vestibular migraine remains underdiagnosed and often misattributed to anxiety or psychosomatic dizziness. Many patients see multiple clinicians over months or years before receiving an accurate diagnosis. 

Contributing factors include:

• Symptom variability
• Overlap with other disorders
• Lack of objective findings
• Limited awareness among clinicians and patients

Treatment

There are no vestibular migraine–specific treatment guidelines; management parallels that of migraine and requires a multimodal approach.

Lifestyle and Trigger Modification

• Regular sleep patterns (and treatment of sleep disorders such as sleep apnea) 
• Consistent meals and hydration 
• Trigger identification and avoidance 
• Stress management 
• Regular physical activity

Preventive Treatments

There are very few randomized controlled trials in vestibular migraine prophylaxis. A qualitative systematic review of vestibular migraine prophylaxis in 2022 included 23 studies with limited data to support the use of the following:⁴

• Tricyclic antidepressants – amitriptyline/nortriptyline
• SNRIs– venlafaxine
• Beta blockers – propranolol
• Calcium channel blockers – flunarizine (not available in the US)
• Antiepileptics – topiramate, sodium valproate, lamotrigine
• Acetazolamide – as this works as a diuretic as well, it should be considered in patients with comorbid Meniere’s disease

Since then, additional studies have shown efficacy in:

• CGRP monoclonal antibodies – galcanezumab⁵
• Gepants – rimegepant⁶
• OnabotulinumtoxinA⁷

Acute Treatments

Data are limited:

• Triptans appear to have limited efficacy⁸
• Gepants may be beneficial⁹
• Vestibular suppressants (e.g., meclizine, benzodiazepines) should be used sparingly and only for severe, prolonged episodes due to the risk of chronic vestibular suppression, no more than 1-2 times per week.  
• Antiemetics (e.g., ondansetron, prochlorperazine) 

Neurostimulation Devices

Emerging evidence suggests that noninvasive vagus nerve stimulation and trigeminal nerve stimulation may have efficacy as both acute and/or preventive therapies, although data remain limited.^10,11,12 Given their potential benefits and favorable safety profiles, they may be promising non-pharmacological treatment options for some patients, although cost and accessibility can be limiting factors.

Vestibular Rehabilitation

Vestibular physical therapy focusing on balance training and habituation can benefit patients, especially those with persistent imbalance or motion hypersensitivity. This approach is often underutilized but can significantly improve functional outcomes.  A systematic review of 11 studies found that vestibular rehabilitation significantly improves vertigo, dizziness, imbalance, headache, anxiety, and depression in adults with vestibular migraine, offering a non-pharmacological option for patients.¹³

Psychological and Behavioral Therapies

For some patients, cognitive-behavioral therapy (CBT), biofeedback, and mindfulness help mitigate stress triggers and improve coping mechanisms. 

Monitoring and Follow-Up

Regular follow-up is essential to:

• Assess treatment response and tolerability
• Adjust therapy
• Re-evaluation of the diagnosis if symptoms evolve
• Monitor for the emergence of overlapping conditions

Symptom diaries and validated outcome measures (e.g., Dizziness Handicap Inventories) can help track progress.

Conclusion and Clinical Implications

Vestibular migraine is an established clinical entity that demands heightened awareness from healthcare professionals across specialties. Its heterogeneous presentation and symptom overlap with other conditions make diagnosis challenging but entirely feasible through careful history and exclusion of alternate diagnoses.

A comprehensive, individualized treatment approach offers the best opportunity for symptom control and improved quality of life. Early recognition and appropriate management can significantly reduce the burden of this often debilitating condition.

References

1. 1. Formeister EJ, Rizk HG, Kohn MA, Sharon JD. The Epidemiology of Vestibular Migraine: A Population-based Survey Study. Otol Neurotol. 2018;39(8):1037-1044. doi:10.1097/MAO.0000000000001900
   2. Espinosa-Sanchez JM, Lopez-Escamez JA. New insights into pathophysiology of vestibular migraine. Front Neurol. 2015;6:12. Published 2015 Feb 6. doi:10.3389/fneur.2015.00012
   3. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: Diagnostic criteria1. J Vestib Res. 2022;32(1):1-6. doi:10.3233/VES-201644
   4. Smyth D, Britton Z, Murdin L, Arshad Q, Kaski D. Vestibular migraine treatment: a comprehensive practical review. Brain. 2022;145(11):3741-3754. doi:10.1093/brain/awac264
   5. Sharon JD, Krauter R, Chae R, et al. A placebo controlled, randomized clinical trial of galcanezumab for vestibular migraine: The INVESTMENT study. Headache. 2024;64(10):1264-1272. doi:10.1111/head.14835
   6. Shao J, Fu J, Zhou M, et al. Effectiveness of rimegepant in vestibular migraine: a prospective self-controlled cohort study. J Headache Pain. 2025;26(1):289. Published 2025 Dec 22. doi:10.1186/s10194-025-02243-5
   7. Aydemir G, Ardıç FN, Kara CO, Değirmenci E. Efficacy of Low-Dose BoNT-A Acupoint Injections in Managing Headache, Vertigo, and Allodynia in Vestibular Migraine. J Int Adv Otol. 2025;21(4):1-6. doi:10.5152/iao.2025.251876
   8. Webster KE, Dor A, Galbraith K, et al. Pharmacological interventions for acute attacks of vestibular migraine. Cochrane Database Syst Rev. 2023;4(4):CD015322. Published 2023 Apr 12. doi:10.1002/14651858.CD015322.pub2
   9. Chu, H., Pan, J. & Huang, C. The efficacy of rimegepant for the acute treatment of vestibular migraine. Sci Rep 16, 9247 (2026). https://doi.org/10.1038/s41598-026-39902-9
   10. Farahani A, Adel Ghahraman M, Togha M, Malmir K, Jalaie S. Effects of adding transcutaneous vagus nerve stimulation to vestibular rehabilitation on dizziness and postural control in vestibular migraine: a randomized clinical trial. Sci Rep. 2026;16(1):8133. Published 2026 Feb 10. doi:10.1038/s41598-026-39697-9
   11. Beh SC. External trigeminal nerve stimulation: Potential rescue treatment for acute vestibular migraine. J Neurol Sci. 2020;408:116550. doi:10.1016/j.jns.2019.116550
   12. Beh SC, Friedman DI. Acute vestibular migraine treatment with noninvasive vagus nerve stimulation. Neurology. 2019;93(18):e1715-e1719. doi:10.1212/WNL.0000000000008388
   13. Sfakianaki I, Nikitas C, Kikidis D. The Effectiveness of Vestibular Rehabilitation in Vestibular Migraine: A Systematic Review. J Assoc Res Otolaryngol. 2026 Apr;27(2):137-166. doi: 10.1007/s10162-026-01042-2. Epub 2026 Mar 16. PMID: 41840297; PMCID: PMC13090472.

Author

Maria Machala is a certified nurse practitioner in the Department of Otolaryngology at the University of Colorado, where she has specialized in otology and neurotology since 2015. She serves as Director of the Dizziness and Balance Clinic at the University of Colorado, a board member of the Vestibular Disorders Association (VeDA), and serves on the Advanced Practice Provider Education Committee for the Association of Migraine Disorders. 

Maria has presented nationally and internationally on vestibular migraine and is actively involved in the education of future healthcare providers. She helped develop the Migraine APPrenticeship program through the Association of Migraine Disorders. 

Her clinical and academic interests focus on vestibular disorders, particularly vestibular migraine and its overlap with Ménière’s disease and other otologic conditions. Through her clinical practice, educational initiatives, and professional leadership, Maria is dedicated to improving the recognition, diagnosis, and treatment of vestibular disorders and advancing care for patients with dizziness and migraine-related conditions.