Vestibular Migraines

Vestibular migraine is a condition characterised by symptoms of dizziness that are moderate to severe intensity and can last seconds, minutes and in some cases up to 72 hours or longer.

Vestibular migraines

These migraines can be characterised by headaches or muzzy feelings on one side, pulsating feelings of moderate to severe intensity and can be aggravated by routine physical activity.

Light and sound sensitivity may feature along with visual auras, nausea and vomiting. Vestibular dizziness and balance symptoms include spontaneous vertigo that is a false sensation of self-motion, internal movement or a false sensation that the visual surroundings are spinning or flowing etc. It can be positional occurring after a change in head position, for example looking down or up.

Vestibular migraine affects women more than men, especially women of child bearing age. Studies show that in headache clinics 27 to 33 percent of patients with headaches and migraine also report dizziness and vertigo (spinning sensation). Up to four out of ten people may not have a headache with their Vestibular Migraine.

What are the symptoms of vestibular migraine?

Below is a list of symptoms that maybe associated with vestibular migraine although they do not always occur together and the list is not exhaustive

• Headache or muzzy sensation
• Moderate to severe unilateral head, neck, and shoulder or body pain
• Light and sound sensitivity (photophobia and phonophobia)
• Sensory aura for example visual aura, numbness, pins and needles etc.
• Spontaneous vertigo such as internal or external sense of movement or spinning
• Dizziness on positional changes of the head
• Visually induced vertigo triggered by a complex or large moving visual stimulus
• Head motion induced dizziness with nausea and or vomiting
• Ear pain, tinnitus and fullness of the ear.

About one third of people with Migraines have warning symptoms, known as aura, before the vestibular migraine.

These include:

• Visual problems (flashing lights, zigzag patterns and blind spots)

• Dizziness, spinning, vertigo or sensations of motion

• Stiffness, pains or a tingling sensation like pins and needles in your neck, shoulders or limb

• Problems with co-ordination, you may feel disorientated or off balanc

• Difficlty speaking

• Loss of consciousness, this only happens in very rare cases and should be confirmed as part of a migraine syndrome by a specialist.

Aura symptoms typically start between 15 minutes and one hour before any headache begins. Some people may experience aura with only a mild headache or no headache at all.

What causes vestibular migraine?

The exact cause of migraine is still unknown however there is some evidence to link changes in the chemicals of the brain. In particular, levels of a chemical called serotonin decrease during migraine. This can make the blood vessels in the brain spasm and narrow.

There is some evidence to suggest a genetic link to certain migraines although it is so common you may know someone in your family who has migraine.

People who are prone to vestibular migraine may have certain triggers that can cause the brain to release chemicals and can result in symptoms such as dizziness, imbalance etc.

Vestibular migraines can co-exist with other headache syndromes eg. cluster headaches, tension type headaches etc.

The common triggers of migraine are:

• Hormonal triggers for example. menstrual or menopausal etc
• Emotional triggers such as stress, fatigue, tension, grief etc (most common)
• Physical triggers such as poor sleep, travel, shoulder tension etc
• Dietary triggers such as dehydration, lack of food, up and down blood sugar levels, alcohol, food additives for example Tyramine, MSG- monosodium glutamate (E621), smoked or cured meats, foods prepared with soy sauce, vinegar, yeast extracts, pickles, alcohol artificial sweeteners, nuts, peanut butter and certain foods such as cheese, chocolate, citrus fruits, alcohol, red wine or anything brewed in oak barrels etc.

Rather than cut all food out it’s useful to keep a diary to help identify triggers as food triggers are not as common as stress, fatigue or weather changes.

• Caffeine products (tea/coffee/ hot chocolate, green tea, cola, energy drinks, chocolate etc.)
• Environmental triggers such as bright lights, flicking screens (TV/ computer), smoking, loud noises, changes in climate, strong smells etc
• Medicines such as some sleeping tablets, contraceptive pill, HRT, pain relief eg. paracetamol, codeine or morphine when taken more than twice a week.

How is the diagnosis made?

There is no specific test to diagnose vestibular migraines. The International Headache Society has a list of diagnostic criteria, which guide the diagnosis.

You will have a physical examination to check your vision, coordination, reflexes and sensations. These checks will be carried out to make sure there are no other underlying conditions causing your symptoms. You may have a scan to rule out any other cause but in most cases this is not necessary.

To help with the diagnosis, it can be useful to keep a diary of your migraine attacks. Write down details, including the date, time, and what you were doing when the migraine began. It is also helpful to make a note of the food you ate that day as this can help identify any potential triggers.

How do you treat Migraine?

If you have symptoms less than 15 days a month, it is classed as an episodic vestibular migraine and if you have symptoms more than 15 days a month it is classed as a chronic vestibular migraine. Vestibular migraines have different treatments depending on whether they are episodic or chronic.

There is currently no cure for migraines. However, a number of treatments can be used to ease the symptoms. Successful management of chronic migraine depends on getting the foundations right. This should be a long term plan and needs to be done consistently to get the best results.

What should I do during an attack?

• Most people find that sleeping or lying in a darkened room is the best thing to do when having a migraine attack or that they start to feel better once they have been sick
• Eating something may help (like a rich tea biscuit)
• Drink one to two pints of water
• The application of ice packs to your head or neck may also help. Evidence suggests cold is better than heat but do whatever makes you feel better.

Certain medications may help ease symptoms during an attack however they should be only taken less than two days a week maximum.

These include:

• Painkillers eg. Paracetamol and Asprin
• Triptan medicines eg. Rizatriptan, Sumatriptan
• Anti-inflammatory medicines eg. Ibuprofen, Diclofenac, Naproxen should you be able to tolerate them. Do not take ibuprofen if you have, or have had in the past, stomach problems, such as a peptic ulcer, or if you have liver or kidney problems.
• Anti sickness drugs and over the counter combination medicines are available at your local pharmacy.

Ask your prescriber or pharmacist if you are not sure which medication is most suitable for you.

Vestibular rehabilitation and balance exercises can be given at low doses and progressively increased within a person’s tolerance and they help desensitise and recalibrate the balance system especially if there is a balance organ component to the dizziness.

In cases where people are visually sensitive (visual vertigo) certain environments can trigger dizziness and balance symptoms such as supermarkets, lifts, shopping centres, stadiums, theatre or travelling on escalators and in these circumstances tailored visual exercises and desensitisation or sensory reweighting programmes can be given to help reduce symptoms. 

Seek urgent treatment if:

• You have your first severe headache that comes on suddenly (within one or two minutes)
• You have a severe headache with fever, sickness and possibly a rash

IMPORTANT: If you have a severe ‘thunderclap’ headache that feels the worst headache you have ever had and reaches maximum intensity in less than five minutes, phone 999.

What are the foundations of good migraine management and how can I prevent a migraine?

• Do NOT take painkillers or acute attack medication daily, take less than twice a week maximum
• No, or limited, amounts of caffeine such as tea, coffee, chocolate
• Maintain good hydration, drink two to three litres of water daily
• Regular mealtimes
• Maintain good sleep hygiene and a regular sleep pattern. Avoid sleeping in.
• Go for a walk or cycle four times a week for 20 to 30 minutes with moderate exertion and head movements with visual targeting of different things in the environment.

If, when the above foundations are in place, you still experience migraine, preventative medication maybe advised.

However, it is very important that painkillers, caffeine, alcohol and sleeping tablets are avoided if possible as this can reduce the effectiveness of the preventative medication.

The medications commonly used for migraine prevention include:

• Antihypertensives (eg. Propranalol, Bisoprolol, Atenolol, Candesartan)
• Tricyclic antidepressants (eg. Nortriptyline, Amitriptyline- off label)
• Anticonvulsants (eg. Topiramate, Lamotrigine)
• Selective Serotonin Reuptake Inhibitors/ Selective Norepinephrine Reuptake Inhibitors (eg. Sertraline, Paroxetine, Venlafaxine)
• Antipsychotics (eg. Olanzapine)
• Calcium channel blockers (eg. Flunarizine).

This list is not exhaustive, and no drug used for any condition is entirely free of side-effects or potential adverse problems.

If you experience a worrying problem on a new drug it is advisable to consult your doctor, prescriber or local pharmacist for advice.

You will see that none of these drugs are specifically called anti-migraine drugs, as they were often found to be helpful in other conditions such as epilepsy or depression before they were shown to help migraine.

However, at low doses, these drugs have shown in clinical trials to help significant numbers of patients with chronic or frequent migraine.

Can supplements help?

Yes. There is some low level evidence to suggest the following supplements may be of benefit but can cause side effects just like medications. It’s useful to keep a diary and trial for three months and stick to one or two at a time:

• Vitamin B2 (Riboflavin) 400mg daily
• Magnesium (malate, glycinate, gluconate) 400-600mh daily
• Vitamin D 500-1000 micrograms
• Vitamin E (menstrual migraines) 400IU daily
• Q10 c-enzyme 300mg daily
• Boswellia 300mg x3 daily (avoid in pregnancy)
• Feverfew 100mg three times daily (avoid in pregnancy)
• Ginger up to 1000mg daily
• Melatonin 3mg daily (usually evening).

Essential oils can help too:

• Peppermint oil (apply to head or skin during an attack or put in a steam bath to inhale).

Brief recap

• Implement and practice prevention of migraines consistently
• Keep a diary of time, mood, sleep, stress, food etc
• Avoid triggers if possible
• Keep well hydrated
• Recognise the signs eg. change in mood, cravings, tiredness, hyperactivity, strange sensations and act quickly
• Know how to manage your attack
• Walk every day in the daylight for 30 minutes briskly and look around taking in the detail of things around you
• Try mindfulness and relaxation with positive thoughts.

Advice and support

You may wish to listen to the ‘Heads Up podcast’ on vestibular migraine on the National Migraine Centre website.

To find out more about migraines and their management, contact The Migraine Trust.

Tel: 020 7631 6975
Email: info@migrainetrust.org

You can also join The Migraine Trust’s online community through Facebook or go to: migraine page on the NHS website or migraine.org.uk website

How to contact us

Admin: 01704 387258

Our patients matter

Mersey Care NHS Foundation Trust listens and responds to patients and their carers to help improve the services we deliver.

If you have any comments,compliments or concerns you can speak with a member of staff or contact our Patient Advice and Liaison Service (PALS) and Complaints Team:

Telephone: 0151 471 2377
Freephone: 0800 328 2941
Email: palsandcomplaints@merseycare.nhs.uk

To request this leaflet in an alternative format or language, please speak to a member of staff. Our patients matter Mersey Care NHS Foundation Trust V7 Building, Kings Business Park, Prescot L34 1PJ