vestibular migraine (VM)

vestibular migraine (VM)

Dizziness Handicap and Anxiety in Patients with BPPV and Migraines

A recent study found that significant differences in perceived handicap scores and levels of anxiety and depression exist between patients diagnosed with benign paroxysmal positional vertigo (BPPV) and those with vestibular migraines. 

Patients with BPPV reported lower scores on the Dizziness Handicap Inventory (DHI) and Hospital Anxiety and Depression Scale (HADS) than patients with vestibular migraines. 

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Photo of an older man receiving vestibular testing

Revolutionize Vestibular Testing: New Ways to Assess Patients with Central Disorders

The patient journey for vestibular assessment can be a lengthy process. A 2011 survey by the Vestibular Disorders Association (VEDA) states that, on average, patients consult four to five doctors before receiving a diagnosis. Furthermore, it takes an average of three to five years for a person with a vestibular disorder to receive a diagnosis (VEDA, 2011). By applying new testing techniques, clinicians can scale down their workflow and obtain an accurate diagnosis in less time.

Topic(s): Encephalopathy, vestibular schwannoma, vestibular migraine (VM), Vestibular, vestibular evaluation

The Audiologist’s Obligation to the Vertiginous Patient

The Audiologist’s Obligation to the Vertiginous Patient

If you’ve ever experienced vertigo, then you’re aware of how horrible this type of dizziness can be. Certainly, talking to a few patients will give you a better understanding of the impact of this symptom on your life. It is incapacitating and there is often a sense of lack of control that can bring on an exacerbating anxiety contribution.

Most audiologists, and frankly many people, have become more familiar with benign paroxysmal positional vertigo (BPPV). There are videos online to help show people how to treat this problem and it is possible to do this successfully. Alternatively, it has been estimated that the annual costs associated with BPPV in the United States exceed $2 billion. How is it that something you can watch on your phone still costs this much to manage?

The reality is that patients (and often health-care professionals) have no idea which ear to treat or treat the wrong type of BPPV with a standard repositioning maneuver. They order many expensive tests (some studies indicate 75 percent of patients with BPPV undergo costly MRI scans). The audiologist is literally in the best position to be able to accurately identify the ear and canal. It should stand to reason, then, that the audiologist is also in the best position to implement the correct management technique to bring about a positive outcome.

Similarly, some would argue that vestibular migraine is one of the most common causes of vertigo and other dizziness. In fact, some recent work suggests that patients diagnosed with other primary causes of vertigo often have vestibular migraine as a secondary diagnosis. The reason for this relationship that appears to exist between vestibular migraine and other causes of dizziness is unknown. What is known is that lifestyle modifications can be very effective in addressing migraine in general.

For example, elimination of triggering food/drink has been shown to cause a significant reduction of migraine symptoms in 63-93 percent of participants. Restful sleep is another factor that seems to improve symptoms of migraine. One study found a 49 percent reduction of headache frequency for the experimental group compared to the control group (25 percent) at six weeks follow-up.

Missing meals or fasting is a trigger in as many as 57 percent of migraineurs. Other researchers have shown that by increasing physical activity through exercise, a 40 percent reduction in migraine headache frequency can be realized. Recommending a “migraine diet” is cited as a first line of intervention in almost all comprehensive articles on management of vestibular migraine. This is a helpful management technique that can be provided by audiologists to the benefit of many patients with this type of migraine.

Management of vestibular impairment is in our scope of practice. By intervening as one of the front-line health-care providers who work with patients with dizziness and imbalance, we can create improvement for the individual. This will decrease the burden of health-care costs, lost days of work, etc.

After attending the Practice Management Specialty Meeting, you will be ready to identify and manage all types of BPPV and provide an initial solution to many patients with vestibular migraine.

About the Presenter

Richard A. Roberts, PhD

Richard A. Roberts, PhD, is vice chair of clinical operations and an assistant Professor in the Department of Hearing and Speech Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.

Learn more from his presentation at the Academy’s Practice Management Meeting, January 9-11, 2020, in Hawaii:
"The Audiologist’s Obligation to the Vertiginous Patient".

Ask the Expert: Vestibular Migraine

Ask the Expert: Vestibular Migraine

Vestibular Migraine: Kristen Steenerson, MD

1. What are the diagnostic criteria for vestibular migraine?

The criteria for vestibular migraine were developed jointly by the Barany Society and the International Headache Society in 2012. As vestibular migraine was still a newly accepted diagnosis at that time, strict diagnostic criteria were developed to establish universal research standards. As a result, many patients who have vestibular migraine may not fit into the classic criteria established over seven years ago. As the current criteria stand, patients are required to have at least five moderate to severe attacks of vertigo (defined as any hallucination of movement, not just spinning) lasting 5 minutes up to 72 hours at a time. With these attacks, migrainous features such as headache, photophobia, phonophobia or visual aura must be present half of the time. Finally, a previous or current history of more classically understood migraine helps to clinch the diagnosis.

2. What are common clinical signs and symptoms for patients with suspected vestibular migraine?

​Patients with vestibular migraine typically have attacks of spinning, tilting, rocking, sway and imbalance. These are usually spontaneous, but can be linked to stress, poor sleep, dehydration, skipping exercise and meals. In between attacks, it is very typical for patients to have hypersensitivity to motion, sound, light, smells and medications. When evaluated by physicians, many of these patients are considered normal. However, with a keen eye, physicians will notice vestibular migraine patients have increased head motion sensitivity, visual motion sensitivity, and postural imbalance with exaggerated sway on occasion compared to patients without VM.

3. Are there specific vestibular tests that you find helpful for diagnosing vestibular migraine?

Unfortunately, there are still no gold standard diagnostic tests for vestibular migraine. Some interesting studies have been published highlighting some patterns in vestibular testing that may be helpful, but these are still in nascent stages and of uncertain generalizability. I find it still very useful to order the full battery of audiovestibular tests to make sure other vestibular disorders have been considered, especially Meniere's Disease, due to the considerable overlap in symptoms. 

4. What management strategies are most helpful?

​There are two main approaches to management: prevention and rescue.

  1. Prevention focuses on reducing the total number of attacks and frequency of attacks that occur. A good prevention plan will reduce severity and frequency by 50%; it is rare that patients will see complete resolution of attacks. Prevention plans include lifestyle changes, medications and physical therapy. Lifestyle changes can be very effective in most patients and may be all that is needed. For lifestyle, we use the mnemonic SEEDS: Sleep, Exercise, Eating, Dehydration and Stress management. Regular sleep, exercise, drinking water (avoiding dehydrating drinks like caffeine/alcohol) and eating schedules can be helpful in reducing triggers for migraine attacks. Stress management is also a key lifestyle modification that comes in different forms for different people: meditation, mindfulness, talk therapy, exercise, work modifications and sometimes medications. Medications used for prevention are borrowed from the migraine headache literature. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. Vestibular physical therapy can help desensitize the brain to head/body motion and visual motion to help reduce triggering of attacks.
  2. Rescue focuses on reducing the duration and severity of an attack when it occurs. Medications typically used include anti-nausea, anti-inflammatory, anti-migraine, anti-histamine and anxiolytic properties that have dual purpose as vestibular suppressants. These medications must be used with caution as they are not intended to be used long term and can have longterm side effects. They are very safe if used a few times a month. 

5. Are medications available for vestibular migraine?

In the United States, we commonly use already-established medications used in migraine headaches. These can range from over the counter nutraceuticals such as magnesium and riboflavin to prescription medications such as antihypertensives, antidepressants, and anti-epileptic medications. These are generally effective, but can sometimes require trialling a few different ones before a patient finds relief. There are no randomized controlled trials that support one medication over another in vestibular migraine in the United States. Europe and other countries have trials supporting the medications flunarizine and cinnarizine, but these are not available in the US. 

6. Is vestibular migraine treated differently than other migraines?

​Yes and no. In many ways the treatments are similar. Due to vestibular migraine's unique motion sensitivity and balance difficulties, there is a singular role for vestibular therapy that is not commonly seen in more typical migraine. As more studies are completed, there may be evidence of unique pathophysiologic processes for vestibular migraine compared to migraine headaches, which may implicate emphasis on different types of medications, but this is yet to be definitively established. 

7. Do you recommend vestibular rehabilitation?

​Yes. In the hands of an experienced vestibular therapist, I find that many vestibular migraineurs improve in terms of balance and motion sensitivities. There are severe cases where even the most gentle of ocular motor or balance exercises exceed the threshold of what a patient can tolerate. For those individuals, we will usually attempt lifestyle and medication interventions first before trying vestibular therapy. 

8. What would you want the general public to know about vestibular migraine?

  1. Vestibular migraine is incredibly common. Up to 3% of the general public has vestibular migraine.
  2. It is important to recognize that headaches do not need to be a prominent feature in order to be diagnosed with vestibular migraine.
  3. It is likely an inherited disorder that can become active with certain environmental factors such as stress, hormone fluctuations (e.g. menopause/perimenopause) and irregular sleep/eating/exercise/drinking schedules.

9. What is your overall key take home message for providers working with patients with suspected vestibular migraine?

Vestibular migraine, like other forms of migraine, is an episodic, neurologic, hypersensitivity disorder. Central nervous system and peripheral nervous system pathways are preferentially affected, resulting in vestibular attacks of variegating types of motion and motion sensitivity. As these pathways can sometimes activate independent from pain pathways, vestibular migraineurs can have isolated vestibular events without headache, thus absence of headache should not dissuade the diagnosis. Lifestyle changes are paramount, medications can be helpful, and physical therapy can be useful for treatment in many of afflicted patients.

10. Are there any other specialties you’ve found helpful to include in a vestibular migraine patient’s plan of care?

Due to known connections between the vestibular circuits and the emotional circuits of the central nervous system, most patients experience an increase in anxiety and/or depression related to their vestibular migraine. Attacks are unpredictable and frightening and if suboptimally controlled can trigger maladaptive coping such as panic attacks, hypervigilance and catastrophization. Due to the connection to mood changes, psychological support such as talk therapy and meditation can be beneficial for coping with this distressing disorder. 


Kristen Steenerson is a board-certified neurologist with fellowship training in otoneurology. After graduating cum laude from Claremont McKenna College where she was honored as an All-American lacrosse defensive player, she continued on to medical school at the University of Utah in Salt Lake City, Utah. She then proceeded to Mayo Clinic in Arizona for neurology residency and a fellowship in otoneurology at Barrow Neurological Institute. Dr. Steenerson joined Stanford with positions in both Otolaryngology-Head and Neck Surgery and Neurology with the goal of jointly addressing the junction of inner ear and brain disorders.


Balance Awareness Week

Balance Awareness Week

The Academy is proud to help support Balance Awareness Week—September 13–19, 2020.

Balance Awareness Week, an observance designated by the Vestibular Disorders Association (VeDA), aims to increase awareness about vestibular disorders and support patients in their journey back to balance. While many balance disorders are incurable, faster and more accurate diagnosis, along with effective coping strategies can greatly improve quality of life.

Audiologists play a key role in helping to diagnose and manage vestibular and balance disorders in adults and children.

The Academy has collaborated with VeDA to develop resources on hearing loss and balance and to help educate other health-care providers, the media, and consumers about the audiologist’s role in balance care.

Download and use this press release template to get the word out through your local media...

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Balance Awareness Week Social Media Graphic


10 Questions for the Experts

Recent Topics in Balance Research

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Falls, Dizziness, Diagnosis, and Medications

Migraine, Meniere’s Disease (MD), and vestibular migraine (VM) likely share a common pathogenesis. Unfortunately,  there is no “gold-standard” lab test to identify the “correct” diagnosis. Further, the audiologist, otolaryngologist, or neurologist (or other) must interpret the case history, physical findings, and test results to establish the differential diagnosis. Unfortunately, overlapping terms may be used to indicate the same (or highly similar) phenomena (Beck et al, 2013).

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