Migraine-Associated Vertigo: Diagnosis and Treatment

Hi All,

A new article in the science literature:

[size=130]Migraine-Associated Vertigo: Diagnosis and Treatment[/size]
Semin Neurol 2010; 30(2): 167-174
Yoon-Hee Cha
Department of Neurology, University of California


Migraine-associated vertigo [size=120]has become a well-recognised disease entity[/size] diagnosed based on a clinical history of recurrent vertigo attacks unexplained by other central or peripheral otologic abnormalities, which occurs in the patient with a history of migraine headaches. There is no international agreement on what spectrum of symptoms should be covered under this diagnosis, or what terminology should be used. The headaches and vestibular symptoms of migraine-associated vertigo may not be temporally associated, which often obscures the association. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms. Management generally follows the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with β blockers, calcium channel blockers, and tricyclic amines. Small case series show that acetazolamide and lamotrigine appear to be more effective for the vertigo attacks than headaches. Vestibular rehabilitation has also been shown to be helpful in several studies. In this review, the epidemiologic and clinical features of the disorder, as well as the current state of knowledge on pathophysiology, diagnostic testing, and treatment are described.




The most interesting part of the abstract was the part about how VRT has shown to help. I was getting better and better at the exercises (head shake stare at paper with x)…like I could do it for longer and with faster motion but it was also inducing headaches so my therapist told me to hold off and see how normal life treats me for awhile. Very interesting, I’ll see what my new doc thinks and mb try a little bit.


I’m interested in this too because, to my knowledge, there is only one paper I’ve seen that addressed VRT in people with MAV. Here they say “several” studies. I’m ordering the paper today. We’ll have the story soon enough because from what I’ve seen on this and other forums, VRT makes people with MAV worse – usually. Rauch says it’s “practically diagnostic for MAV” if VRT makes a person feel worse.

Best … Scott

Hi All,

I’ve added the link above for downloading. This paper summarises the data. One thing they said that sure hits home for me is this:

“Development and persistence of concurrent anxiety and affective disorders are more common in patients with vestibular migraine than in patients with other vestibular disorders.”


Thanks for posting this. I’ve just skim-read it and am very surprised to see it reports at least 2 studies have shown betahistine is helpful with MAV. Ill see if I can get hold of the original papers. Honestly, this is is a direct contradiction to what I was told And I therefore stopped taking it! And now I’m worse. And someone on this forum reckoned it made MAV worse. What with this and the VRT conflicting opinions it makes me think no one has a bl**dy clue!

I might just restart my betahistine to see what happens!

A very confused Izzy who’s still dizzy

The VRT thing is confusing. Logically, it seems to me that if migraine is the cause of vertigo than it makes little sense to be doing VRT while migraine is active. When the migraine passes, balance should be restored to normal. The only reason I can see VRT being useful for MAV is when:

  1. migraine has somehow severely disrupted the vestibular system (permanently altering calcium channels for example) and requiring brain recalibration.
  2. the person has had previous vestibular damage from, say, VN and migraine is acting solely as a complicatiing cofactor – but even then VRT is probably of little use until the migraine is controlled.
  3. the person with MAV has had a BPPV attack which can leave residual symptoms requiring VRT.

Anything I missed?


Number 3) the person with MAV has had a BPPV attack which can leave residual symptoms requiring VRT.

is Totally on the ball Scott
I think this is why some recover and some just become worse, due to VRT.

I was seeing a Physiotherapist doing VRT, before diagnosed, she was a therapist devoted to helping dizzy patients.
I told her I received my Diagnosis, her reply was , well I’ll be of no use to you then, as You have to stop the migriane cycle first .

Like Joe, I occasionally do, Brandt-Daroff maneuvers, and with persistence they help.
so those darn little crystals break up and move back to where they’re supposed to be.
Betahistine may also work for those migrianeurs that have a build up of fluid around the timpanic drum, due to migraine.


Thanks Jenny and Scott, that seems a reasonable explanation. My consultant did actually ask me if I felt off balance between attacks b4 she recommended VRT and I do have a vestibular asymmetry. The day I saw her and had the tests I was feeling well (that is to start with!!!) so I guess the VRT is for the residual imbalance. However, even on good days I have for a long time noticed I feel funny eg when getting out of a lift (elevator) and I had to quit dance classes as I couldn’t do the turns!

My assumption was/is that years of undiagnosed/untreated MAV have somehow caused damage to the vestibular system, and this is what the VRT will address. Do you think I’m barking up the wrong tree here? The leaflet the hospital gave me does say avoid VRT during an actual migraine, but when I phoned the physio up she said it made no difference if I had migraine on the day.

So I’m concerned the physio may be barking up the wrong tree too! Apparently I’m part of her PhD project.

Ah - I’ve just realised my theory is the same as Scott’s theory no. 1.

Right, I am on the warpath! I’ve read this paper again, and I am not convined the author knows his a**e from his elbow (for some reason I’m assuming it’s a ‘he’). Notwithstanding the dodgy proof-reading as indicated by the greengrocer’s apostrophe, I’ve checked out the so-called ‘several studies’ showing VRT is useful in MAV. This bit comes under the section entitled ‘Vestibular Rehabilitation’ on p.172.

If you read it, there are 5 references in this section. Of these 5, two clearly relate to ‘concurrent anxiety and affective disorders’ (reference 86 and 87), NOT to VRT. Of the other 3 (all of which I have managed to get hold of in their entirety), one, reference 44 (Migraine-associated Dizziness: Patient Characteristics and Management Options, by Mark D. Reploeg and Joel A. Goebel), although an interesting paper, makes no mention of VRT!!!. The other two, references 84 (Physical Therapy for Migraine-Related Vestibulopathy and Vestibular Dysfunction With History of Migraine, by Susan L. Whitney, Diane M. Wrisley, Kathryn E. Brown and Joseph M. Furman) and 85 (Vestibular Rehabilitation Outcomes in Patients with a History of Migraine, by Diane M. Wrisley, Susan L. Whitney, and Joseph M. Furman) are clearly written by the same bunch, both retrospective case-series designs! I wonder if they used the same data/subjects!?

So Dr Yoon-Hee Cha’s ‘several studies’ seems to mean at best 2! Unless I’m missing something.

Scott, you said you only knew of one study - which one is that? Is it the same bunch?

Calming down a bit now…



I love how you dig into the science lit like this. Thanks for checking his refs. I was skeptical when I saw that written in the abstract. There is ONE that I have somewhere I will post here later. It’s bull about there being “several” studies showing VRT being useful for MAV.

You’re right too (from a previous post) that just because something makes it into the science literature that it makes it “rock-solid”. You really have to know how to sift out the gold nuggets. Most are pretty good but even some Cochrane reviews are a joke IMO – particularly one on acupuncture that comes to mind.


Hi Scott,

Like Jenny said whenever i have a vertigo episode (which is very seldom) i generally use the Brandt-Daroff exercises for a few days and the vertigo subsides. Recently the 3d movie i saw really messed me up and i ended up having vertigo the following morning. It took over 3 weeks of doing the Brandt-Daroff exercises (one or twice a day) before the vertigo calmed down. But of course it does not appear to take away the motion feeling in my head. But atleast the spinning has subsided. I’m still trying to find the right medication for the motion/pultze like feeling in my head.


I have had vestibular rehabilatation 3 times. Each time I went for months and never improved. I just got releaed from the third time as the therpist said I wasnt improving. They also had some machine they would put me in and the walls and floor would move. It also was supposed to see which system was working to help with balance it showed my vestibular system was bad and I was using my eye sight to try to compensate for it. I cant remember what the third system was this brain fog is killing me today.