A poorly understood form of migraine primarily marked by dizziness rather than headache is challenging to diagnose and manage, experts say, as it falls between neurology and otology specialties. Vestibular migraine affects the inner ear’s balance system, causing symptoms such as vertigo, disequilibrium, and sensitivity to light and sound, often without the characteristic headache typically associated with migraines.
Alicia Wolf, a Dallas-based watch designer, first experienced these symptoms a decade ago after returning from overseas travel. Despite multiple consultations with ear, nose, and throat specialists, neurologists, and other doctors, her diagnosis remained elusive for months. Initial assessments often dismissed her symptoms as anxiety or depression before an emergency room doctor noted vertigo and, eventually, she was diagnosed with vestibular migraine.
According to a 2018 study, approximately 3 percent of the U.S. population may suffer from vestibular migraine, although this figure is believed to be underestimated. The study also found that only 10 percent of patients with vestibular migraine are correctly informed that their dizziness results from migraine. Dr. Jeffrey Sharon of the University of California, San Francisco, described vestibular migraine as an underrecognized condition, attributing its complexity to the overlap of migraine symptoms with sensory processing disorder and balance system dysfunction.
Vestibular migraine involves hypersensitivity in the vestibular system—the part of the inner ear and brain responsible for balance and coordination. During episodes, abnormal activity in the brain triggers the trigeminal nerve, leading to the release of calcitonin gene-related peptides (CGRP), which inflame blood vessels and heighten nerve sensitivity. This process causes an exaggerated response to stimuli such as light, sound, and movement.
Despite growing awareness among specialists, many primary care physicians remain unfamiliar with the disorder, contributing to delays in diagnosis. Common misdiagnoses include Ménieré’s disease and persistent postural-perceptual dizziness. Factors associated with increased risk include being female, under 40, and having a history of anxiety, depression, or head trauma. A migraine history in any form may also predispose individuals to vestibular migraine, even if prior headaches have subsided.
Diagnosis typically involves ruling out other causes through hearing tests, MRIs, and vision assessments. Treatment approaches are highly individualized, often combining medication, lifestyle changes, and supplements. There is no one-size-fits-all protocol, and responses to treatments vary.
In Wolf’s case, a neurologist specializing in vestibular disorders identified changes in brain scans consistent with migraine activity. Following a tailored treatment plan including beta blocker eye drops, anti-anxiety medication, and supplements such as magnesium and vitamin B2, along with lifestyle modifications like reducing stress and eliminating alcohol and caffeine, her symptoms gradually subsided over several years.
Recent research has focused on the role of CGRP in vestibular migraine. Drugs targeting CGRP, originally developed for other migraines, have shown promise in reducing dizziness. A 2024 study demonstrated that galcanezumab, a CGRP inhibitor, was more effective than placebo in alleviating vestibular migraine symptoms. However, definitive large-scale trials are still lacking, and some patients report only limited benefits. Conversely, triptans, widely used for migraine headaches, have shown minimal effectiveness for vestibular migraine.
Experts emphasize the need for further research to clarify the distinct mechanisms of vestibular migraine. Dr. Sharon noted that while vestibular migraine shares characteristics with other migraine types, it remains a complex condition requiring specialized understanding to improve diagnosis and develop targeted therapies.