Not All Migraines Create Headaches

Vestibular migraine is more than a migraine with dizziness—and not everyone with vestibular migraine experiences a headache. Vertigo, motion sensitivity, visual intolerance, imbalance, and other vestibular symptoms may be the most prominent features, making this condition easy to overlook or misdiagnose. In this article, I explain what vestibular migraine can look like, how it is diagnosed, what happens during and between migraine attacks, and where vestibular rehabilitation may fit into treatment.

This condition, like other vestibular disorders, is very complex and each individual experiences them differently. However, the overarching similarities are as follows:

1. Vestibular symptoms are typically moderate to severe and occur in episodes lasting anywhere from 5 minutes to 72 hours. Some patients have one right after the other, giving the impression that their symptoms are continuous or never-ending.

2. Most patients have a history of migraine and often have other non-vestibular symptoms that accompany the vestibular migraine, such as headaches, light sensitivity, or sound sensitivity.

3. Symptoms are generally not caused by head movement itself, although movement often worsens symptoms during an attack. Many people notice that quick head turns, walking through busy environments, or riding in a car become much more uncomfortable once a migraine has started.

4. Many people feel completely normal between migraine attacks, while others continue to experience mild motion sensitivity or imbalance. Vestibular testing may be completely normal between episodes, which is one reason vestibular migraine can be difficult to diagnose.

Some patients experience positional vertigo, which is bursts of (usually) a spinning sensation similar to another vestibular condition, BPPV (benign paroxysmal positional vertigo). Others feel a more constant internal sense of dizziness that is worse with certain movements. Yet others will feel dizziness that is visually induced. For example, they may not tolerate scrolling on their phones or busy environments such as stores can be overwhelming.

One of the primary treatments for migraines is medication. The medication profiles are preventative, meaning you would take them regularly to prevent migraines, and abortive, meaning you take them during a migraine to stop the symptoms quickly. Please consult with you medical provider to discuss the treatment options that are best for you.

Another primary treatment or recommendation is managing the triggers that bring on migraines. Common triggers include stress, poor sleep, dehydration, skipped meals, hormonal fluctuations, certain foods or beverages, weather changes, and sensory overload. Triggers vary greatly from person to person. Keeping a journal can be very helpful in identifying the pattern to the migraine and what the triggers might be. Keep in mind you may have multiple triggers.

Another treatment option that has gained popularity is the Cefaly® device (along with similar devices from other manufacturers). This small wearable device attaches to the forehead and delivers gentle electrical stimulation to branches of the trigeminal nerve, one of the primary nerves involved in migraine. While researchers are still learning exactly how it works, the stimulation appears to calm the brain's migraine pathways and reduce how easily they become activated. Depending on the treatment program selected, it can be used either during a migraine attack to lessen symptoms or on a regular basis to help prevent future attacks. Some insurance plans may cover the device, although coverage varies.

What should someone with migraine do if they are having dizziness or trouble with balance? The answer depends on when they have those symptoms. If it is during the active part of the migraine, abortive medications can stop the symptoms in that moment. Breath work and grounding strategies are also calming and can minimize symptoms as well. If you are very unstable, then moving more cautiously is appropriate.

If your dizziness occurs between migraine attacks (the interictal period) or after the attack has resolved (the postdrome or "migraine hangover" phase), vestibular rehabilitation may be appropriate. This is the ideal time to work on motion sensitivity, balance, gaze stability, and confidence with movement. Trying to perform these exercises during an active migraine attack often makes symptoms worse and is generally not recommended.

Vestibular migraine is one of the most common conditions associated with Persistent Postural-Perceptual Dizziness (PPPD). In some people, repeated migraine attacks can contribute to the development of persistent dizziness, motion sensitivity, and visual dependence even after the migraine episode has ended. Early diagnosis and appropriate treatment may reduce the risk of these secondary problems and improve overall quality of life.

If your imaging is normal or you've seen multiple providers without answers, vestibular migraine may be worth discussing with your healthcare provider. Vestibular rehabilitation cannot treat the migraine itself, but it can address the lingering balance, gaze stability, and motion sensitivity problems that often remain between attacks.

If you're wondering whether vestibular therapy could be helpful for you, I'd be happy to answer your questions or schedule an evaluation. Reach out to me directly at 808-210-4458 via text or phone call.

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