A diagnosis of migraine isn’t truly a complete diagnosis without specifying which form or forms of migraine we have. As we look for information and talk with others, we hear about many different forms of migraine, so many, in fact, that it can be somewhat overwhelming. It can also be problematic because different people, including doctors, can mean different things when they talk about forms of Migraine. For that reason, the International Headache Society’s (IHS) International Classification of Headache Disorders (ICHD) is the gold standard for classifying migraine and other headache disorders.
Over the years, many people have talked about vestibular migraine, but there was no such diagnosis within the ICHD. In the third edition released last year (ICHD-3), vestibular migraine has been addressed. The Classification Committee of the IHS has added it to the appendix in ICHD-3. The primary purpose of the appendix is to:
“…present research criteria for a number of novel entities that have not been sufficiently validated by research conducted so far. The experience of the experts in the Classification Committee, and publications of variable quality, suggest that there are still a number of diagnostic entities that are believed to be real but for which better scientific evidence must be presented before they can be formally accepted.”
It’s common for disorders that appear in the appendix of the ICHD to be moved to the main body in the next edition.
All of that said, what is vestibular migraine? In the past, it’s been called migraine-associated vertigo/dizziness, migraine-related vestibulopathy, and migrainous vertigo. I’ll include the IHS description and diagnostic information below, but here are the basics:
For a diagnosis of vestibular migraine, there must be a history of migraine without aura or migraine with aura.
Vestibular migraine can occur with or without aura.
Mild or moderate vestibular symptoms between five minutes and 72 hours. Vestibular symptoms include:
internal vertigo (a false sensation of self-motion);
external vertigo (a false sensation that the visual surround is spinning or flowing);
positional vertigo, occurring after a change of head position;
visually induced vertigo, triggered by a complex or large moving visual stimulus;
head motion-induced vertigo, occurring during head motion;
head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
At least 50% of episodes are associated with at least one of the following three migrainous features:
headache with at least two of the following four characteristics:
moderate or severe intensity
aggravation by routine physical activity
photophobia and phonophobia
A simplified definition is that vestibular migraine is migraine with or without aura with mild or moderate vestibular symptoms lasting between five minutes and 72 hours. It can be difficult to know if we’re experiencing dizziness or vertigo. Dizziness is most often described as feeling faint or lightheaded. If you have trouble distinguishing between the two, make notes about how you feel as soon as possible, while it’s fresh in your mind, and discuss them with your doctor.
A1.6.5 Vestibular migraine
Previously used terms:
Migraine-associated vertigo/dizziness; migraine-related vestibulopathy; migrainous vertigo.
- At least five episodes fulfilling criteria C and D
- A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura1
- Vestibular symptoms2 of moderate or severe intensity,3 lasting between 5 minutes and 72 hours4
- At least 50% of episodes are associated with at least one of the following three migrainous features5:
- headache with at least two of the following four characteristics:
- unilateral location
- pulsating quality
- moderate or severe intensity
- aggravation by routine physical activity
- photophobia and phonophobia6
- visual aura7
- Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder8.
- Code also for the underlying migraine diagnosis.
- Vestibular symptoms, as defined by the BÃ¡rÃ¡ny Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of A1.6.5 Vestibular migraine, include:
- spontaneous vertigo:
- internal vertigo (a false sensation of self-motion);
- external vertigo (a false sensation that the visual surround is spinning or flowing);
- positional vertigo, occurring after a change of head position;
- visually induced vertigo, triggered by a complex or large moving visual stimulus;
- head motion-induced vertigo, occurring during head motion;
- head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
- Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued.
- Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.
- One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.
- Phonophobia is defined as sound-induced discomfort. It is a transient and bilateral phenomenon that must be differentiated from recruitment, which is often unilateral and persistent. Recruitment leads to an enhanced perception and often distortion of loud sounds in an ear with decreased hearing.
- Visual auras are characterized by bright scintillating lights or zigzag lines, often with a scotoma that interferes with reading. Visual auras typically expand over 5-20 minutes and last for less than 60 minutes. They are often, but not always restricted to one hemifield. Other types of migraine aura, for example somatosensory or dysphasic aura, are not included as diagnostic criteria because their phenomenology is less specific and most patients also have visual auras.
- History and physical examinations do not suggest another vestibular disorder or such a disorder has been considered but ruled out by appropriate investigations or such a disorder is present as a comorbid or independent condition, but episodes can be clearly differentiated. Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks.
Other symptoms: Transient auditory symptoms, nausea, vomiting, prostration and susceptibility to motion sickness may be associated with A1.6.5 Vestibular migraine. However, as they also occur with various other vestibular disorders, they are not included as diagnostic criteria.
We can work best with our doctors as treatment partners when we know our full diagnosis. If you’ve only been given a diagnosis of “migraine,” ask your doctor to be more specific. This is also helpful when looking for more information and when talking with others.
Vestibular migraine can occur with or without aura. A migraineur diagnosed with vestibular migraine will often be given multiple diagnoses. Our migraines aren’t always the same. Someone with vestibular migraine may not always have the vestibular symptoms, so will often also be diagnoses with migraine with or without aura, or both, ending in three diagnoses - vestibular migraine, migraine with aura, and migraine without aura. As research continues, and doctors see more people who meet the ICHD-3 appendix criteria for vestibular migraine, it may well be moved into the main body of the ICHD in the next edition.
Headache Classification Committee of the International Headache Society. "The International Classification of Headache Disorders, 3rd edition (beta version)." Cephalalgia. July 2013 vol. 33 no. 9 629-808 10.1177/0333102413485658
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Teri Robert is a leading patient educator and advocate and the author of Living Well with Migraine Disease and Headaches. A co-founder of the Alliance for Headache Disorders Advocacy and the American Headache and Migraine Association, she received the National Headache Foundation’s Patient Partners Award and a Distinguished Service Award from the American Headache Society. Teri can be found on her website, and blog, Facebook, Twitter, StumbleUpon, Pinterest, LinkedIn, and Google+.