Vestibular Migraine Diagnosis Criteria

From National Library of Medicine

Criteria Summary

Vestibular Migraine Diagnosis Criteria: symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

Vestibular Migraine Diagnostic Criteria

• At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 min to 72 hours
• Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
• One or more migraine features with at least 50% of the vestibular episodes:
  • headache with at least two of the following characteristics: one sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity
  • photophobia and phonophobia,
  • visual aura
• Not better accounted for by another vestibular or ICHD diagnosis

Definitions

• Vestibular symptoms:
  • spontaneous vertigo including
    • internal vertigo, a false sensation of self-motion, and
    • 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 prohibit daily activities and “severe” if 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 four weeks to fully recover from an episode. However, the core episode rarely exceeds 72 hours
• Migraine categories 1.1 and 1.2 of the ICDH-3
• 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.
• Visual auras are characterized by bright scintillating lights or zigzag lines, often with a scotoma that interferes with reading.
• History and physical examinations do not suggest another vestibular disorder or such a disorder is considered but ruled out by appropriate investigations or such disorder is present as a comorbid or independent condition, but episodes can be clearly differentiated.

Epidemiology

Vestibular migraine is one of the most common vestibular disorders affecting between 1% and 2.7% of the general population, 11% of patients in specialized dizziness clinics and 13% of patients in headache clinics. About 65% to 85% of the patients are female. Familial occurrence of vestibular migraine with autosomal dominant inheritance has been documented in several families.

Relation to migraine aura and migraine with brainstem aura

Both migraine aura and migraine with brainstem aura are terms defined by the ICHD-3 (Chronic Migraine). Only a minority of patients with vestibular migraine experience their vertigo in the time frame of 5–60 minutes as defined for an aura. Even fewer have their vertigo immediately before headache starts, as would be required for the ICHD-3 category typical aura with headache. Therefore, episodes of vestibular migraine cannot be regarded as migraine auras.

Relation to benign paroxysmal vertigo of childhood/vestibular migraine of childhood

The ICHD-3 defines benign paroxysmal vertigo (of childhood) as an episodic syndrome that may be associated with migraine. The diagnosis requires five episodes of severe vertigo, occurring without warning and resolving spontaneously after minutes to hours. In between episodes, neurological examination, audiometry, vestibular functions and EEG must be normal.

Other symptoms

The current classification restricts the diagnosis of vestibular migraine to patients with vertigo and accepts patients with dizziness only when they have head-motion induced dizziness with nausea.

Transient auditory symptoms nausea, vomiting, prostration, unsteadiness and susceptibility to motion sickness may be associated with vestibular migraine.

Results of vestibular testing

Vestibular migraine is classified entirely on the basis of clinical features as reported by the patient. Just as in migraine itself, there are no biological markers for vestibular migraine

Overlap with Menière’s disease

Migraine is more common in patients with Menière’s disease than in healthy controls. Patients with features of both Menière’s disease and vestibular migraine have been repeatedly reported. Fluctuating hearing loss, tinnitus and aural pressure may occur in vestibular migraine, but hearing loss does not progress to profound levels. Moreover, chronic hearing loss in VM is usually bilateral and downsloping as compared to unilateral or asymmetric and flat in chronic Menière’s disease.

When the criteria for Menière’s disease are met, particularly unilateral hearing loss as documented by audiometry, Menière’s disease should be diagnosed, even if migraine symptoms occur during the vestibular attacks. Only patients who have two different types of attacks, one fulfilling the criteria for vestibular migraine and the other for Menière’s disease, should be diagnosed with the two disorders.

Other differential diagnoses

Vestibular migraine may present with purely positional vertigo, thus mimicking BPPV. Direct nystagmus observation during the acute phase may be required for differentiation.

Transient ischemic attacks (TIAs). A differential diagnosis of vertebrobasilar TIAs must be considered particularly in elderly patients.

Vestibular paroxysmia presents with brief attacks of vertigo, lasting from one to several seconds, which recur many times per day. Successful prevention of attacks with carbamazepine supports the diagnosis.

Psychiatric dizziness. Anxiety and depression may cause dizziness and likewise complicate a vestibular disorder.

Migraine induced by vestibular activation

Caloric stimulation often triggers migraine attacks within 24 hours in patients with migraine, which shows that migraine attacks can be a secondary effect of vestibular activation rather than its cause in susceptible individuals.

Provoking factors

Provocation of an episode can be a diagnostic clue. Menstruation, stress, lack of sleep, dehydration, and certain foods may all trigger migraine attacks, but are not included as diagnostic criteria for vestibular migraine, because their sensitivity and specificity have not been adequately studied.

Response to antimigraine medication

A favorable response to anti-migraine drugs may support the suspicion of an underlying migraine mechanism. So far, the evidence for treating vestibular migraine with anti-migraine drugs is insufficient as it is mostly based on observational studies rather than randomized controlled trials. Consequently, a positive drug response is not regarded as a reliable criterion for the diagnosis of vestibular migraine

Chronic vestibular migraine

In this classification, vestibular migraine is conceptualized as an episodic disorder. However, a chronic variant of vestibular migraine has been reported. Between attacks, many patients experience some degree of visually-induced, head motion-induced or persistent dizziness. A distinction between chronic vestibular migraine, motion sickness and comorbid persistent postural-perceptual dizziness seems particularly challenging in these patients.