Vestibular Migraine: A Primer

Shin C. Beh, MD


November 08, 2019

Editorial Collaboration

Medscape &


The recurrent episodes that the patient described (a sensation of falling and spinning, accompanied by photophobia, phonophobia, and postural imbalance lasting for hours) are consistent with vestibular migraine.[1]

The diagnosis of vestibular migraine is made using the International Headache Society–Bárány Society consensus criteria,[1] which require the following:

  • at least five episodes of vestibular symptoms lasting between 5 minutes and 72 hours

  • current or previous history of migraine, with or without aura

  • at least 50% of the vestibular episodes must be associated with one or more migraine features:

    • headache with at least two of the following characteristics: unilateral, pulsating, moderate or severe pain intensity, aggravated by routine physical activity

    • photophobia and phonophobia

    • visual aura

  • not better accounted for by another headache disorder or by another vestibular disorder

Differential diagnoses for vestibular migraine include Meniere disease (MD) and migraine with brainstem aura. Auditory symptoms are not uncommon in vestibular migraine and may mimic manifestations of MD.[2] MD typically causes unilateral auditory symptoms (ear fullness, muffled hearing, and roaring tinnitus) preceding the onset of vertigo. These episodes last between 20 minutes and 12 hours.[2] Furthermore, the diagnosis of MD requires documentation of fluctuating sensorineural hearing loss or low-frequency hearing loss on audiometry examination.[2] When assessing a patient with episodic vertigo and auditory symptoms, audiometry is useful to test for asymmetric low-frequency hearing loss, as this is a distinguishing factor of MD.

A diagnosis of migraine with brainstem aura requires a migraine aura that is accompanied by at least two fully reversible brainstem symptoms (vertigo, dysarthria, tinnitus, hypacusis, diplopia, ataxia not attributable to a sensory deficit, and decreased level of consciousness) and without any motor or retinal symptoms.[3] The patient did not meet criteria for migraine with brainstem aura because his vertigo and tinnitus were not followed by migraine headache and did not last between 5 and 60 minutes.

The patient's episodes of feeling that he was growing smaller are consistent with somesthetic dysperceptions (ie, misperceptions of body image) characteristic of Alice in Wonderland syndrome,[4] an unusual disorder of perception that is most commonly caused by migraine in adults.[4]

Usually, Alice in Wonderland syndrome manifests with visual misperceptions. For instance, patients may describe objects as appearing larger, smaller, closer, or farther away than they actually are.

Another form of dysperception that may be experienced is somesthetic distortion, whereby patients may describe feeling that they are bigger or smaller than they actually are, or they may feel that certain body parts are disproportionately larger or smaller. Although migraine is the most common etiology of Alice in Wonderland syndrome, there are many possible causes, including epilepsy, toxic-metabolic encephalopathy, and viral infections.[5] It is prudent to order EEG, brain MRI, and blood tests to evaluate for other causes of Alice in Wonderland syndrome. The treatment of these illusions depends on the underlying cause.

The patient was prescribed rizatriptan as a rescue medication for these episodes, which he found beneficial if used at the early signs of oncoming headache. For migraine prevention, he was unable to tolerate nortriptyline or amitriptyline, and was apprehensive of topiramate's potential adverse effects, including nephrolithiasis, paresthesia, and cognitive slowing. He was started on lamotrigine, which reduced the frequency of these episodes by more than 50%.


Comments on Medscape are moderated and should be professional in tone and on topic. You must declare any conflicts of interest related to your comments and responses. Please see our Commenting Guide for further information. We reserve the right to remove posts at our sole discretion.