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A vestibular migraine is a type of migraine that is characterized by symptoms related to the vestibular system, which contributes to your sense of balance and spatial orientation. Unlike typical migraines, vestibular migraines may not always cause a headache; instead, they are associated with dizziness, vertigo, and problems with coordination.
During a migraine attack we see abnormal electrical activity called Cortical Spreading Depression (CSD), and it represents a wave of increased activity of nerve cells, followed by decreased activity. CSD is believed to trigger various neurotransmitters and inflammatory substances and causes blood flow changes. Serotonin levels drop during a migraine attack, potentially contributing to the initiation of the attack phase. Serotonin is an important chemical involved in the regulation of pain pathways, blood vessel constriction, and our mood. We also see trigeminal nerve activation, which is a major cranial nerve responsible for sensation in the face and head. Activation of the trigeminal nerve leads to the release of neuropeptides (CPRG, substance P, etc.) and inflammatory substances, contributing to pain and blood vessel dilation. Inflammation in the meninges (the protective layers surrounding the brain) may contribute to pain and other symptoms associated with migraines.
The reason why some people get migraines and others don’t is thought to come down to inherited abnormalities of our ion channels. Our ion channels control chemicals into and out of the cell, and thus control the electrical activity of the nerve cells. People with migraines may represent a set of biochemical abnormalities in these gates, making them “primed” to generate this abnormal electrical activity. This, in combination with other triggers, may push them over the threshold and generate a migraine attack.
Central sensitization is one of the leading causes to chronicity of migraines. Over time, repeated migraine attacks may lead to central sensitization, where the nervous system becomes more responsive to stimuli, making individuals more susceptible to migraines and increasing the severity of attacks.
Migraine is common, affecting ~12% of the population, and Vestibular Migraine, a subset of migraine affects up to 3% of the population.
The most common age of onset is between 30-50 years of age, though migraine disease can occur at any age.
It is more common in females than males, anywhere from 3-6x more likely.
78% experience a history of car sickness.
Benign Paroxysmal Positional Vertigo (BPPV) and Persistent Postural Perceptual Dizziness (PPPD) are common in people with vestibular migraine.
Many people with vestibular migraine often report anxiety, depression and sleep issues.
Migraine often occur in several phases, although not everyone with migraines experiences all of these phases. The five main phases of a migraine are:
Prodrome (Premonitory Phase): This phase can occur hours to days before the onset of the migraine attack. Symptoms during this phase may include mood changes, food cravings, increased thirst, neck stiffness, increased yawning, and frequent urination. Not everyone experiences prodrome, and the symptoms can vary widely.
Aura (if applicable): Not all people with migraine experience an aura. An aura is a set of neurological symptoms that typically precede the onset of the migraine attack. Auras are usually visual disturbances, such as flashes of light, zigzag lines, or blind spots. However, auras can also involve other neurological symptoms, like tingling sensations in the face or hands. Aura symptoms usually last for about 20 minutes to an hour and resolve before the headache begins.
Attack: This is the phase most commonly associated with migraine. Common symptoms include vertigo (a spinning sensation), dizziness, problems with balance and coordination, and sometimes visual disturbances. Unlike typical migraines, the headache may be mild or absent during this phase. The attack phase can last from a few hours to several days. During this phase, individuals may also experience other symptoms such as sensitivity to light, sound, and smells, nausea, and vomiting.
Postdrome (Recovery Phase): After the attack phase resolves, some people experience a postdrome, also known as the "migraine hangover." During this phase, individuals may feel fatigued, have difficulty concentrating, experience mood changes (such as irritability or elation), and have lingering attack symptoms. The postdrome can last for a day or two.
Interictal Phase: This refers to the period between migraine attacks when an individual is not experiencing active symptoms. During the interictal phase, individuals may feel relatively normal without the acute symptoms that are typical during a vestibular migraine episode. However, some people may still experience residual symptoms, such as mild imbalance, sensitivity to motion, or other subtle issues related to the vestibular system. It's crucial to understand that the interictal phase is a time when the individual is in a sort of "migraine-free" period, but they may still be at risk of experiencing another vestibular migraine in the future.
Common signs and symptoms of vestibular migraine include:
Vertigo: A spinning sensation or feeling like the room is moving.
Dizziness: A general feeling of unsteadiness. This can be constant, brought on with head motion and/or position changes.
Problems with balance and coordination: Difficulty walking or performing tasks that require coordination. A sensation that you are being pulled to one side.
Nausea and vomiting
Motion Sensitivity: symptoms are brought on by being in a vehicle or other modes of transportation, elevators, or moving our head or bodies quickly
Sensitivity to Visual Motion: Increased sensitivity certain visual stimuli such as action movies, traffic, grocery store, scrolling on a device, busy carpets or wallpapers.
Visual Disturbances: Some people may experience visual symptoms such as blurred vision, visual aura, or sensitivity to light.
Ear Symptoms: Ear pain, ear or head fullness, tinnitus, sound sensitivity and fluctuating hearing loss.
Headache and Neck Tension: similar to that of a typical migraine and often occurs on just one side of the head or face. It's important to note that not everyone with vestibular migraines will experience a headache.
Sinus Symptoms: sinus pressure, runny nose, cough, and a sore throat.
Digestive Changes: Constipation or diahhrea can occur, along with appetite changes and food cravings.
Congitive Changes: Fatigue, brain fog and confused thinking
The Migraine Threshold Theory is an explanation for the triggers and underlying mechanisms that lead to the onset of migraine attacks. According to this theory, individuals have a certain threshold for developing a migraine, and when certain factors surpass this threshold, a migraine attack is triggered. This theory helps to explain why some people are more prone to a migraine than others and why certain factors may precipitate migraine episodes in susceptible individuals.
Each person has a unique threshold level for developing a migraine. This threshold is influenced by a combination of genetic, environmental, and lifestyle factors. When the cumulative impact of triggers surpasses an individual's threshold, a migraine attack is initiated.
Various factors, known as triggers, can contribute to surpassing the migraine threshold. Triggers can be diverse and include:
Changes in weather
Exposure to certain odors or pollutants
Allergies
Bright lights
Loud noises
Irregular sleep patterns
Stress
Dietary factors (e.g., certain foods or drinks)
Exposure to visual stimuli
Fluctuations in estrogen levels, often associated with the menstrual cycle or perimenopause/menopause.
Dehydration
Intense physical activity
Skipping meals
Travel
Smells
Understanding the Migraine Threshold Theory is essential for managing a migraine disease. Individuals can work with healthcare professionals to identify their specific triggers and develop strategies to stay below their migraine threshold. Lifestyle modifications, stress management, and sometimes medications are used to help prevent or alleviate migraines by keeping trigger levels below the individual's threshold.
In addition, vestibular physiotherapy can help to raise an individual’s migraine threshold, which reduces the number of attacks as well as many interictal symptoms between attacks.
Diagnosis is typically based on a thorough medical history, symptom evaluation, and ruling out other potential causes of similar symptoms. Below is the diagnostic criteria for a vestibular migraine:
A) At least 5 episodes of vestibular symptoms of moderate or severe intensity, lasting 5 minutes to 72 hours
B) Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
C) One of more migraine features with at least 50% of the vestibular episodes
Headaches with at least two of the following characteristics: unilateral, pulsating/throbbing, moderate or severe intensity, aggravated by routing physical activity
Photophobia and phonophobia
Visual aura
D) Not better accounted for by another vestibular or ICHD diagnosis
The treatment of vestibular migraine involves a combination of lifestyle modifications, acute treatment for symptoms during an episode, and preventive measures to reduce the frequency and severity of attacks. It's important to note that the specific approach to treatment may vary for each individual, and a personalized approach is the most effective. Your treatment may begin with one practitioner, however often the most effective treatment involves a multi-disciplinary approach.
Here are common strategies used in the management of vestibular migraine:
Keeping a migraine diary or using our migraine tracker handout to identify and avoid specific triggers that may be contributing to vestibular migraine episodes.
Migraine tracker apps can also be useful for on the go tracking. Our favourite options include Canadian Migraine Tracker by Migraine Canada, Migraine Insight and Migraine Buddy.
Dietary Changes: Identifying and avoiding potential trigger foods such as caffeine, alcohol, and certain additives. In addition, avoiding skipping meals and instead eat consistently. For more on dietary changes, we recommend The Dizzy Cook.
Regular Sleep Patterns: Maintaining consistent sleep schedules and ensuring adequate sleep.
Hydration: Staying well-hydrated and avoiding dehydration, which can be a trigger for some individuals. Electrolytes can also be effective in maintaining adequate hydration levels.
Exercise: Low-intensity, vestibular-friendly aerobic exercise with the guidance of a healthcare professional
Stress Management: Incorporating stress-reduction techniques such as relaxation exercises, meditation, and yoga. For more about the connection between dizziness, stress and anxiety, check out this blog post.
Rescue Medications: Depending on the severity of symptoms, healthcare professionals may prescribe medications to alleviate acute symptoms. These may include pain relievers, anti-nausea medications, or medications specifically targeting vestibular symptoms.
Migraine Rescue Kit: It is important to be prepared and create a migraine attack rescue kit. Items such as ginger chews, ear loops, FL41 tinted glasses, essential oils, magnesium, a snack, and electrolytes can be included. For more information, check out this blog post and our Migraine Rescue Kit Amazon Page.
Anti-migraine Medications: Certain medications used for migraine prevention may be effective in reducing the frequency and severity of vestibular migraines. These may include beta-blockers, calcium channel blockers, tricyclic antidepressants, and antiepileptic drugs.
Supplements: Magnesium, Riboflavin (B2) and CoQ10 and some of the common supplements have been shown to help vestibular migraine. You can find examples of supplement to purchase here.
Vestibular physiotherapy focuses on improving balance and verticality as well as reducing symptoms of dizziness and motion sensitivity.
Improves pain and tightness in the neck, shoulders and upper back.
Physiotherapy also addresses common comorbidities associated with vestibular migraine, including BPPV, PPPD and Meniere’s Disease.
Note that vestibular physiotherapy must be initiated with an advanced vestibular therapist familiar with migraine.
CBT can be beneficial for managing stress, which is a common trigger for migraines.
For individuals whose vestibular migraine are associated with hormonal fluctuations, hormonal therapies or adjustments may be considered.
It's crucial for individuals with vestibular migraine to work closely with their healthcare providers to develop a comprehensive and personalized treatment plan. Regular follow-ups are important to monitor the effectiveness of the chosen interventions and make adjustments as needed.
Vestibular Migraine treatment is most effective with a team approach including vestibular physiotherapists, neurologists, otolaryngologists and family physicians.
Healing Vertigo has advanced vestibular physiotherapists with experience in treating vestibular migraine. We provide care in-person at our clinic in Hamilton as well as virtually to individuals across Ontario. We will work with you and your local community of healthcare providers to ensure full collaborative care is provided. Contact us today to learn more or book an appointment.
Disclaimer: This advice is not meant to be a substitute for advice from a medical professional regarding diagnosis, prognosis, or treatment. Always seek advice from your physician, physiotherapist, or other qualified healthcare provider with questions you may have regarding a healthcare condition. The information of this website and email, including but not limiting to text, graphics, videos, images, and other materials are for informational purposes only. Reliance on the information on this website and email is soley at your own risk.