Vestibular Migraine

Summary

Migraines can occur throughout the brain, causing a variety of symptoms on the basis of their location. For example, migraines that occur in some areas of the brain cause head-splitting pain, while migraines in the visual cortex can cause visual hallucinations known as ‘auras.’ [C] Vestibular migraines occur in the vestibular system and can cause vertigo, dizziness, balance disturbance, disequilibrium, motion sensitivity, and more. As a disorder, vestibular migraine is extremely common. An estimated 1% of people in the U.S. suffer from migrainous vertigo, which is widely accepted as the second most common cause of spontaneous episodic vertigo 6,1. 1%– that’s approximately 3 million people! Even with these staggering statistics, vestibular migraine is still dramatically under-diagnosed. Because there is no objective test for diagnosing vestibular migraine, doctors must rule out a number of other conditions first before a determination is made.

Symptoms of Vestibular Migraine

The symptoms of vestibular migraine are not well defined, which partially explains why the disorder is so under-diagnosed. As stated in Lempert et al. (2012), ‘…the lack of a universally accepted definition of vestibular migraine has hampered patient identification in clinical and research settings.’ (To see the exact diagnostic criteria for vestibular migraine, click the link above.) I have done my best to accumulate a list of symptoms from the literature, which are listed below:

  • Episodic vestibular symptoms lasting 5 minutes to 72 hours or even weeks of moderate to severe intensity
  • List of Vestibular Symptoms: 
    • Dizziness
    • Spatial Disorientation / Detachment
      • Difficulty Walking (the feeling that your legs are not coordinated)
      • Difficulty Standing (the feeling that the ground beneath you is unstable)
    • Spontaneous Vertigo
      • Internal Vertigo (false sense that you’re moving)
      • External Vertigo (false sense that the world around you is spinning, rocking, flowing, etc.)
    • Positional Vertigo (caused by change in position)
    • Visually-induced Vertigo
      • Motion Sensitivity (Sensitivity to visual motion while in a car, watching videos on a screen, scrolling on a cell phone, etc.)
    • Nystagmus (rapid involuntary movements of the eyes)
    • Somatosensory Impairment (inaccurate sensation of your spatial orientation due to tactile deficits)
    • Balance Disturbance / Ataxia
  • History of migraine (either personally or family history)
  • Potential Migraine Features associated with the majority of vestibular episodes including:
    • Headache
    • Head Pressure (sinus pressure behind eyes/in forehead or behind ears)
    • Cerebral Hemispheric (half of the head) Tendency
      • Unilateral Pulsating Sensation
      • Facial Numbness, Tingling, Drooping, Lagging (one-sided)
        • Causes difficulty speaking, or visual problems
    • Sensory Exaggeration, including:
      • Photophobia (sensitivity to light)
      • Phonophobia (sensitivity to sound– especially buzzing, rumbling, or percussive tapping)
      • Motion Sensitivity
    • Tinnitus (ringing in the ears)
    • Visual Aura
    • Nausea / Vomiting

Treatment for Vestibular Migraine

The treatment for vestibular migraine is not unlike the treatment for standard migraine symptoms, but with a few additions. Like migraine disorder, the best treatment for vestibular migraine is trigger avoidance. Depending on the breadth, severity, and cause of vestibular symptoms, vestibular therapy may be necessary. Below is a step-by-step list of treatment options for vestibular migraineurs:

1. Trigger Avoidance / Lifestyle Changes

While there are many migraine triggers that are uncontrollable (i.e. stress, weather, hormones, etc.), there are some triggers whose influence can be controlled or minimized. This primarily includes diet, but also includes stress reduction techniques, allergen therapy, improved sleep hygiene, adequate hydration, and more. For a complete list of migraine triggers, click here. For a list of trigger foods, click here.

2. Anti-Migraine Mediations

Prophylactic / Preventative Medications:

There are no prophylactic migraine medications designed specifically to treat migraines. Instead, there are medications designed for other neurologic dysfunctions that are used to alleviate abnormal brain activity (cortical excitation / neuronal hyperactivity) characteristic of migraines. These can include betablockers, anticonvulsants, antidepressants, and calcium antagonists.

Supplements

To be honest, I don’t know much about medicines and supplements, because I haven’t done much research into them so far. I can list, however, the supplements I have come across in my readings: Magnesium, B2 (riboflavin), CoQ10, feverfew, butterbur. When I get a chance, I will come back and look into the literature to see if these are supported. Personally, I take magnesium 250mg 2-3x/day, which helps tremendously.

3. Vestibular Therapy / Rehabilitation

Vestibular therapy can be critical to the recovery of some patients, namely those experiencing vestibular deficits or complications. From Bisdorff 2011: vestibular rehabilitation is ‘…particularly useful for complications of vestibular migraine such as anxiety, visual dependence or loss of confidence in the balance system.’ In studies such as Whitney et al. 2000 and Wrisley et al. 2002, vestibular migraine patients have improved both subjectively and objectively after participating in vestibular rehabilitation.

Speaking from personal experience, I have found vestibular therapy to be invaluable to my recovery process. Primarily, my vestibular therapist is able to give me strategies for coping with dizziness that allow me to partake in daily activities even in the presence of mild dizziness and motion sensitivity. Also, I have found that exercises such as Vestibular Ocular Reflex (VORs) immediately alleviate my symptoms of spatial detachment and internal/external vertigo.

4. Biofeedback

Biofeedback is a technique in which you learn to control processes in your body that are generally considered to be involuntary, including: breathing, heart rate, muscle tension, blood pressure, skin temperature, pain perception, and even brain waves5. It is scientifically proven to be an effective strategy in the treatment of migraine, anxiety, depression, and chronic pain 1,2,3,7. In fact, a study conducted by the world-renowned Jefferson Headache Center in Philadelphia showed that 100% of their patients receiving 7 or more sessions of biofeedback reported headache status improvement. Of those patients, 75% reported a reduction in headache frequency, and 60% reported a decrease in headache intensity. Additional studies conducted by Holroyd and Penzien (1990)2 and Kaushik et al. (2005)3 comparing biofeedback directly to pharmacological methods of migraine control rated certain medicines as equally effective to this form of therapy. The latter study by Kaushik et al. (2005)3 took these results a step further by examining the long-term effectiveness of pharmacological methods versus biofeedback, and found that after one year post-treatment, biofeedback was significantly better than pharmacological methods in reducing migraine prophylaxis. So how does biofeedback work? To learn more, click here.