What is vestibular migraine?

By: Dr. Daniel Larson, MD
Southwest Ohio ENT Specialists

Migraines are very common. Classically people often think of migraine with severe headache. Usually migraine is thought of as a pounding headache with nausea and vomiting and sensitivity to light. Currently, 28 million Americans have classic migraines. People are astonished when they find out that migraine is as common as asthma and diabetes combined. Females are more likely than males to suffer from migraine. Migraine typically presents between the third and fifth decades. Unfortunately migraines can be a lifelong problem. As a patient ages there’s typically a decline in migraine symptoms due to multiple factors; the person is able to learn triggers, for females who have hormone related migraine the symptoms may improve after menopause, migraines have some form of genetic component and many migraine sufferers have been diagnosed and are currently receiving treatments. Generally though, migraine is not a progressive condition The sad truth is that only about one third of migraine patients have controlled symptoms.

Migraine can cause dizziness?

Vestibular migraine is a condition that may cause vertigo, imbalance, brain fog, spaciness, and many other types of dizziness. In classic migraine about 40% of patients experience vertigo. Patients who suffer from vestibular migraine may not have headache at all. (Baloh 3)People with vestibular migraine may experience symptoms for just a few minutes or may extend to multiple days. For patients that do experience headache, the vestibular symptoms may present as an aura which then is followed by headache or they have a headache and then develop dizziness. People suffering from vestibular migraine often experience nausea and vomiting but may also suffer from sensitivity to light or sounds. Patients with a family history of migraine, even without a personal history of migraine, may develop vestibular migraine. There is not an agreed consensus for the pathophysiology of vestibular migraine however it is thought that activation of the trigeminal vascular system (nerves and blood vessels that supply the inner ear) leads to otologic (ear) symptoms. Stimulation, activation or irritation of the trigeminal nerve (nerve to the blood vessels that supply blood to the inner ear) alter the homeostasis (electrolytes and water balance). Studies have shown that stimulation of this nerve can reproduce otologic symptoms. Inversely, stimulation of the inner ear causes release of neurotransmitters to the trigemino-vascular system.

What other symptoms may I experience from migraine?

Migraine can trigger many different types of neurologic symptoms. Activation of the visual system can result in wavy lines(scintillation), blind spots (scotoma), or bright flashes. Migraine patients often experience brain fog or inability to speak, this may be due to a disturbance in the cortical regions. Teeth, sinuses, neck, shoulders, scalp are innervated by the trigeminal nerve. Irritation of this nerve may cause referred pain in these areas.
Traditionally, this was considered a headache-based problem, we now know that migraine can cause many symptoms in addition to headache. Patients may experience sinus migraine which present as recurrent sinus infections. These patients can experience significant facial pain, pressure and nasal congestion. If a patient experiences vestibular or otologic migraine they may experience ear fullness, pressure, pain, ringing, hearing loss, vertigo or balance disturbance.

What are potential causes of migraine?

There are many theories for the source of migraine however there is no consensus. Migraines are often described as a “hot brain”. This means that people with migraine have an increased sensitivity, increased irritability or low threshold to particular environmental stimuli. Some believe this may be due to defective ion channels which alter the electrolytes. For this reason many patients have noticed that excessive salt intake or dehydration is a trigger. This is also the reason why anti-seizure medication such as Topamax is an effective migraine treatment. Another theory is that migraine is a result of spasm and dilation of blood vessels, for those blood pressure medication such as beta blockers can be helpful. The most widely excepted theory is a trigemino-vascular theory which is a combination of electrolyte disturbance, neural activation and changes in blood flow particularly to the fifth cranial nerve, known as the trigeminal nerve which provides sensation to many areas.

What are “triggers”?

A trigger is anything that could potentially activate the migraine process. And to make it more challenging the trigger is not always consistent. The challenge with migraine is that there are a multitude of potential triggers. Typically it is not just one trigger that will activate the migraine but the collection or summation of triggers. It’s not possible to objectively identify the threshold. When the addition of triggers cross the threshold, that is when symptoms are activated. Everyone’s threshold is different and thresholds can also be altered with medical intervention.

It can be challenging to identify triggers because symptoms are not always immediate. They may occur 24 to 48 hours after exposure.

It’s not always a single trigger that creates a migraine. Frustration with inconsistencies of the triggers is understandable and can easily occur. Realizing and appreciating the interaction between the potential triggers helps in the management of those triggers. For example, if a patient believes that chocolate is a trigger and then they enjoy chocolate while on vacation and don’t get migraine symptoms, they may become confused. This can occur for many reasons; stress levels are low, potential allergy exposure is low, the patient is getting good sleep and/or they are not drinking or eating other potential triggers while on vacation.The total sum of the triggers in this case is below the threshold.

Many people are able to identify the triggers by keeping a journal. There is a process to tracking and it can be a tedious task. Therefore, it is often helpful to have a vestibular therapist or other provider as a guide.

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