Home / Conditions / Vestibular migraine
Migraine that attacks your balance rather than your head. About half of episodes come with no headache at all, which is why people spend years being investigated for an ear problem before anyone suggests migraine.
Vestibular migraine is a disorder of the nervous system causing repeated episodes of vertigo or dizziness in people who have migraine. "Vestibular" refers to the inner ear and the parts of the brain that handle balance and eye movement.
The same disturbance that produces a migraine headache also reaches the balance pathways. In some people it does both. In many it does only the second — which is why the diagnosis is missed so often.
It is also called migrainous vertigo or migraine-associated dizziness, and it affects roughly one to three people in a hundred, more commonly women, and particularly around hormonal changes.
Someone with recurring vertigo and no headache does not think "migraine", and neither, often, does the first doctor they see. The natural assumption is the inner ear, and that is where investigation usually starts.
The result is a familiar pattern: normal hearing tests, a normal scan, positional testing that finds nothing, and a conclusion that nothing is wrong — despite episodes that stop someone driving or working. Normal tests are entirely consistent with vestibular migraine. There is nothing for them to find.
What identifies it is pattern recognition rather than a test — and the pattern is only obvious to someone who sees the whole range of migraine regularly. Vertigo with no headache does not look like migraine until you have watched it behave like one: the same triggers, the same light and sound sensitivity, the same response to migraine treatment.
Dr Tung has specialised in neurosurgery since 1991, and headache and migraine are a substantial part of his practice — not only the classic presentations but migraine without headache, cluster headache, headache referred from the neck and this one. Recognising which of them you have is most of the work, and it is what the first appointment is for.
The defining feature is vertigo — not lightheadedness, but the false sensation that you or the room is moving.
Episodes last from a few minutes to a few days. Many people describe the between-times as not quite normal either — a persistent sense of being on a boat.
Three conditions account for most recurring vertigo, and they are distinguishable. This is what an assessment is sorting out.
| Vestibular migraine | BPPV | Ménière's disease | |
|---|---|---|---|
| Episode length | Minutes to days | Seconds to a minute | 20 minutes to hours |
| Trigger | Migraine triggers; also motion | A specific head position | Often none identifiable |
| Hearing | Usually normal | Normal | Loss, typically progressive |
| Light and sound | Often sensitive | — | — |
| Migraine history | Usually present | Not relevant | Not relevant |
Largely the same as for migraine generally, and identifying yours is the highest-yield thing you can do:
Keep a diary for two to four weeks before your appointment. Note when each episode began, how long it lasted, what you had eaten and how you had slept, and whether a headache came with it. With a condition that has no confirmatory test, that record is the most valuable thing you can bring.
There is no blood test or scan that confirms it. Diagnosis works by recognising the pattern and excluding the alternatives — which is why normal test results are part of the picture rather than evidence against it.
Assessment involves a neurological examination, eye movement testing, and hearing tests where one-sided hearing loss or tinnitus is present. Imaging is used to exclude other causes rather than to confirm this one.
It responds well to treatment, and the approach is migraine treatment rather than balance treatment — which is the practical reason the diagnosis matters.
Regular sleep on a consistent schedule, regular meals, adequate hydration, and avoiding the triggers a diary identifies. This sounds slight and is not: for many people it is the single largest factor in how often episodes occur.
Where episodes are frequent, medication taken regularly can reduce how often they happen. Several classes are used — the same ones used in migraine prevention generally — and which suits depends on your history and what else you take.
A specific exercise programme that retrains how the brain handles balance signals, reducing the sensitivity to motion that persists between episodes. It is targeted work, not general physiotherapy, and it addresses what medication does not.
Treatment can be directed at the nerves involved — occipital nerve treatments, pulsed radiofrequency and neuromodulation are part of Dr Tung's practice, and apply here as they do to migraine more generally.
Sudden severe vertigo with double vision, slurred speech, weakness, numbness, or an inability to stand can indicate a stroke affecting the balance centres, and needs same-day assessment at an emergency department.
New one-sided hearing loss with vertigo also warrants prompt assessment rather than being attributed to migraine.
Yes, and roughly half of episodes occur without one. Some people have never had a typical migraine headache at all, though most have a history of migraine at some point. The absence of head pain is the main reason the diagnosis is delayed.
Normal results are expected in vestibular migraine — there is no structural abnormality to find. The tests are done to exclude other causes, and normal results support the diagnosis rather than contradicting it.
BPPV produces brief vertigo, seconds to a minute, triggered by a specific head position, and is often resolved with a repositioning manoeuvre. Vestibular migraine lasts minutes to days and is not tied to one position.
No. Ménière's involves progressive hearing loss in the affected ear; vestibular migraine usually leaves hearing normal. They can be confused early on, which is why hearing is tested.
It tends to fluctuate over years, with better and worse periods, and often eases with age. More usefully, it responds well to treatment — most people can reduce the frequency substantially once the diagnosis is right.
No. You can book directly. Bring any hearing tests and scans you have had, and your diary if you have kept one.
Dizziness and vertigo · Migraine · Silent migraine · Headaches (all types) · Stroke · Neuromodulation
If you have been told nothing is wrong but the episodes keep coming, that is worth a second look. Bring your diary if you have one.
