GPAtlas🧭 When to suspect
Suspect vestibular migraine in any patient with recurrent episodes of moderate-to-severe vertigo – rotational spinning, a rocking or swaying sensation, or feeling 'at sea' – on a background of current or past migraine. It is the commonest cause of recurrent spontaneous (episodic) vertigo in adults and the second commonest cause of vertigo overall after BPPV, yet it is widely underdiagnosed and frequently mislabelled as BPPV, Ménière's disease or anxiety.
The single most useful – and most counterintuitive – point is that a headache does NOT need to be present during the vertigo for the diagnosis to be made. What matters is a history of migraine plus migrainous features (such as light or sound sensitivity, or visual aura) accompanying the attacks.
| Diagnostic criterion (Bárány / ICHD-3) | What is required |
|---|---|
| A – Episodes | ≥ 5 episodes of vestibular symptoms of moderate or severe intensity, each lasting 5 minutes to 72 hours. |
| B – Migraine history | A current or previous history of migraine, with or without aura. |
| C – Migrainous features | ≥ 1 migraine feature in ≥ 50% of episodes: a migrainous headache (≥ 2 of unilateral, pulsating, moderate/severe, worse with activity), photophobia and phonophobia, or visual aura. |
| D – Exclusion | Not better explained by another vestibular or headache disorder. |
Source: Bárány Society & International Headache Society · BMJ
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