Vestibular Migraine: Symptoms, Causes, and Treatment

If you've been experiencing episodes of vertigo, dizziness, or unsteadiness (maybe with headache, maybe without) and you have a history of migraines, you may have a condition called vestibular migraine. As a vestibular therapist, I work with many patients who have this condition, and I want to help you understand what's happening and what we can do about it.

What Is Vestibular Migraine?

Vestibular migraine is a type of migraine where the main feature is recurrent episodes of vertigo or dizziness, rather than just headache. It's actually the most common cause of spontaneous episodic vertigo and the second most common cause of vertigo overall (after BPPV). About 1-3% of the general population has vestibular migraine, and it accounts for 10-30% of patients seen in dizziness-focused practices.

Here's what surprises many people: you don't have to have a headache during your dizzy spells to have vestibular migraine. In fact, the vestibular symptoms and headache often occur at different times, and some people have vestibular migraine episodes with no headache at all.

Who Gets Vestibular Migraine?

Vestibular migraine has a strong female predominance, up to 5 women for every 1 man affected. It often begins several years after typical migraine headaches start, and interestingly, it sometimes appears when headaches are becoming less frequent. This is particularly common in perimenopausal women, where vestibular symptoms may replace headaches as the primary migraine manifestation.

If you have a history of migraine (even if your headaches have improved or stopped) you're more likely to develop vestibular migraine.

What Does Vestibular Migraine Feel Like?

The vestibular symptoms of vestibular migraine can vary quite a bit from person to person, and even from episode to episode in the same person. Common symptoms include:

• Spinning vertigo (feeling like you or the room is rotating)

• Swaying or rocking sensations

• Unsteadiness or imbalance

• Dizziness with head movement

• Positional dizziness (triggered by certain head positions)

• Visual motion sensitivity (difficulty in busy visual environments)

Episodes typically last between 5 minutes and 72 hours, though the duration can vary widely. During at least half of your episodes, you'll likely experience one or more migraine features:

• Headache (one-sided, pulsating, moderate to severe)

• Sensitivity to light (photophobia)

• Sensitivity to sound (phonophobia)

• Visual aura (seeing spots, lines, or other visual disturbances)

Many patients also experience nausea, and some have transient hearing symptoms like ear fullness or ringing.

I can’t overstate how unique symptoms can be for individuals. I’ve recommended Dr. Shin Beh’s book “Victory Over Vestibular Migraine”to many patients with this condition. People often find the section on symptoms to be comforting, as they thought they sounded crazy describing things like “shrinking sensations” or seeing “sparkly electric blobs” in their vision.

What Triggers Vestibular Migraine?

The same triggers that set off migraine headaches can trigger vestibular migraine episodes:

• Stress and anxiety

• Irregular sleep (too much or too little)

• Hormonal changes (menstruation, perimenopause)

• Certain foods and drinks (alcohol, caffeine, aged cheeses, processed foods)

• Dehydration

• Weather changes

• Intense sensory stimulation (bright lights, loud sounds, strong smells)

• Physical exertion

Identifying and managing your personal triggers is one of the most important steps in controlling vestibular migraine.

How Is Vestibular Migraine Diagnosed?

Vestibular migraine is diagnosed based on your symptoms and history. There's no blood test or scan that confirms it, although MRIs can sometimes show signs consistent with chronic migraines. The diagnostic criteria require:

1. At least 5 episodes of moderate to severe vestibular symptoms lasting 5 minutes to 72 hours

2. A current or past history of migraine

3. Migraine features (headache, light/sound sensitivity, or visual aura) occurring with at least half of your vestibular episodes

4. Symptoms not better explained by another vestibular disorder

Your doctor will want to rule out other conditions that can cause similar symptoms, such as Meniere's disease, BPPV, or vestibular neuritis. Standard vestibular testing may be normal or show subtle abnormalities. Vestibular migraines sometimes overlap with another more persistent form of dizziness called PPPD, which is something an experienced vestibular therapist should be able to help with.

Why Does Migraine Cause Dizziness?

We don't fully understand the exact mechanism, but researchers believe vestibular migraine involves abnormal activity in brain areas that process both pain and balance information. The same neural pathways and neurotransmitters involved in migraine headache appear to affect the vestibular system.

There are strong connections between the brainstem areas that control balance and those involved in migraine. When a migraine is triggered, these connections can cause vestibular symptoms even without significant headache.

How Is Vestibular Migraine Treated?

Treatment for vestibular migraine typically involves a combination of approaches:

1. Lifestyle Modifications

This is always the first step and can be remarkably effective:

• Identify and avoid your personal triggers

• Maintain regular sleep patterns (same bedtime and wake time daily)

• Stay well-hydrated

• Exercise regularly (more info on this to come!)

• Manage stress through relaxation techniques, meditation, or biofeedback

• Consider dietary modifications (reducing caffeine, alcohol, and processed foods)

Many patients see significant improvement with lifestyle changes alone, especially if attacks are infrequent.

2. Acute Treatment (For Active Episodes)

When an attack occurs, treatment focuses on relieving symptoms:

• Vestibular suppressants like meclizine or dimenhydrinate can help reduce vertigo and nausea

• Anti-nausea medications like metoclopramide or ondansetron

• Triptans (like rizatriptan or sumatriptan) may help some patients, though the evidence is still developing

A recent clinical trial found that rizatriptan was well-tolerated for vestibular migraine attacks, though more research is needed to confirm its effectiveness.

3. Preventive Medications

If you're having frequent attacks (generally more than 2-4 per month), your doctor may recommend daily preventive medication:

• Beta-blockers (propranolol, metoprolol)

• Calcium channel blockers (flunarizine, verapamil)

• Antidepressants (amitriptyline, venlafaxine)

• Anticonvulsants (topiramate, valproic acid)

• CGRP inhibitors (newer migraine medications like erenumab or galcanezumab)

Finding the right preventive medication often takes some trial and error, and it may take 2-3 months to see the full benefit.

4. Nutraceuticals

Another common approach to migraine management is non-prescription supplements. It’s important to consult your physician prior to initiating new supplements as these can be inappropriate for some individuals and sometimes interact with medications. It’s also important to stick with the regimen (if it’s well tolerated) as it can take a few months for benefits to be realized. Common supplements include:

• Magnesium

• Vitamin B12 (riboflavin)

• Coenzyme Q10 (CoQ10)

5. Vestibular Rehabilitation Therapy

This is where I come in as your vestibular therapist, and this is an important part of treatment that's often overlooked.

How Can Vestibular Rehabilitation Help?

You might wonder: if vestibular migraine is a brain problem, how can physical therapy help? The answer is that vestibular rehabilitation addresses the functional consequences of vestibular migraine and can actually help reduce symptoms. Some patients notice that dizziness or motion sensitivity continues even between migraine attacks. This happens because migraine can temporarily make the brain more sensitive to motion and sensory input. As a result, normal movement such as turning the head, scrolling on a phone, or walking through busy environments may feel overwhelming to the balance system. This increased sensitivity is one reason vestibular rehabilitation therapy (VRT) can be helpful. VRT helps retrain the brain to better tolerate motion and sensory input again.

Research shows that vestibular rehabilitation produces clinically significant improvements in patients with vestibular migraine. A recent meta-analysis found that vestibular rehabilitation reduced Dizziness Handicap Inventory scores by an average of 29 points—well above the 18-point threshold considered clinically meaningful.

Here's what vestibular rehabilitation can do for vestibular migraine:

Reduce Visual Motion Sensitivity

Many vestibular migraine patients become overly sensitive to visual motion. Busy environments like grocery stores, scrolling on screens, or watching action movies become overwhelming at times. We use specific habituation exercises to gradually reduce this sensitivity.

Improve Balance and Gait

Studies show that vestibular rehabilitation significantly improves balance and walking ability in vestibular migraine patients. We work on exercises that challenge your balance system in progressively more difficult ways.

Decrease Dizziness with Head Movement

If turning your head or looking up triggers dizziness, we use gaze stabilization exercises to retrain the connection between your eyes and inner ear.

Address Anxiety

Here's something important: research shows that even vestibular migraine patients with significant anxiety benefit from vestibular rehabilitation. In one study, 58% of vestibular migraine patients had panic-anxiety symptoms, but both anxious and non-anxious patients improved with therapy.

Build Confidence

Chronic dizziness often leads to fear of movement and activity avoidance. Vestibular rehabilitation helps you gradually return to activities you've been avoiding, rebuilding your confidence.

What Does Vestibular Rehabilitation Involve?

A typical vestibular rehabilitation program for vestibular migraine includes:

Habituation Exercises

Repeated exposure to movements or visual stimuli that trigger mild dizziness, helping your brain become less reactive over time.

Gaze Stabilization Exercises

Exercises that train your eyes and inner ear to work together during head movement, reducing dizziness when you turn your head.

Balance Training

Progressive exercises that challenge your balance on different surfaces, with different visual conditions, and during various activities.

Aerobic Exercise

Performing moderate intensity aerobic exercise for 30-60 minutes, 3 times per week, for about 10 weeks, was found to be highly beneficial in reducing migraines (severity, duration, frequency), particularly when combined with appropriate medication. It can be helpful to have guidance when initiating a new exercise routine to improve your exercise tolerance in a way that doesn't trigger symptoms.

Education

Understanding your condition is powerful. In my experience, understanding what is causing your symptoms is often times as important as the exercises themselves in terms of feeling better. We'll discuss triggers, pacing strategies, and how to manage flare-ups.

What Can You Expect?

Recovery from vestibular migraine is possible, but it's important to have realistic expectations:

• Vestibular migraine is typically a chronic condition that requires ongoing management

• Most patients see significant improvement with proper treatment

• Complete elimination of episodes may not be possible, but reducing their frequency and severity is achievable

• Treatment often requires a combination of approaches (lifestyle, medication, and rehabilitation)

• Improvement takes time (usually weeks to months)

Research suggests that the prognosis for vestibular migraine may be somewhat less favorable than for migraine headaches alone, which is why comprehensive treatment is so important.

Tips for Living with Vestibular Migraine

Based on my experience working with vestibular migraine patients, here's my advice:

1. Keep a symptom diary. Track your episodes, potential triggers, sleep, stress, and diet. Patterns often emerge that help guide treatment.

2. Prioritize sleep. Irregular sleep is one of the most common triggers. Aim for consistent sleep and wake times, even on weekends.

3. Stay active. While intense exercise can trigger attacks in some people, regular moderate exercise actually helps prevent migraines. Find your balance.

4. Don't avoid everything. It's tempting to avoid activities that might trigger symptoms, but too much avoidance can make you more sensitive over time.

5. Manage stress. Easier said than done, but stress management is crucial. Consider meditation, yoga, or other relaxation techniques.

6. Stay hydrated. Dehydration is a common and easily preventable trigger.

7. Be patient with medications. Preventive medications take time to work, and finding the right one may require trying several options.

8. Communicate with your healthcare team. Vestibular migraine is best managed with a team approach: you working together with your neurologist or ENT and your vestibular therapist.

9. FL-41 rose tinted lenses. Often overlooked—this is a special tint applied to lenses that most patients describe as instantly relaxing or they feel “it takes the edge off”. They are great for use under fluorescent lights, busy environments, or unavoidable prolonged screen time, but at a minimum they are great to have when you feel the first signs of migraine. You can find my favorite brand on my recommended products page.

When to Seek Help

Contact your doctor if you experience:

• New or different symptoms

• Significantly worsening episodes

• Hearing loss

• Severe headache unlike your usual migraines

• Neurological symptoms like weakness, numbness, or difficulty speaking

• Episodes that don't respond to your usual treatments

The Bottom Line

Vestibular migraine can be a challenging condition, but it's treatable. With the right combination of lifestyle modifications, medications when needed, and vestibular rehabilitation, most patients achieve significant improvement in their symptoms and quality of life.

As your vestibular therapist, my role is to help you understand your condition, develop strategies to manage it, and guide you through exercises that can reduce your symptoms and improve your function. You don't have to navigate this alone.

If you're struggling with dizziness and have a history of migraines, talk to your doctor about whether vestibular migraine might be the cause, and ask about vestibular rehabilitation as part of your treatment plan.

At StillPoint Balance & Dizziness, care focuses on helping clients understand the underlying cause of dizziness and developing a personalized treatment plan to help restore stability and confidence in movement. If you’re in Texas, take the first step and schedule a free consultation to see if we are the right fit for your recovery journey.

This information is intended for educational purposes and should not replace medical evaluation or diagnosis. If you are experiencing new or severe dizziness, consult a qualified healthcare professional.

• References

  1. Rizatriptan vs Placebo for Attacks of Vestibular Migraine. Staab JP, Eggers SDZ, Jen JC, et al. JAMA Neurology. 2025;82(7):676-686. doi:10.1001/jamaneurol.2025.1006.

  2. Vestibular Migraine: Clinical Aspects and Pathophysiology. Furman JM, Marcus DA, Balaban CD. The Lancet. Neurology. 2013;12(7):706-15. doi:10.1016/S1474-4422(13)70107-8.

  3. An Overview of the Current and Emerging Treatment Options for Vestibular Migraine. Calandre EP, Bassila C, Slim M, Rico-Villademoros F. Expert Review of Neurotherapeutics. 2024;24(12):1157-1179. doi:10.1080/14737175.2024.2405739.

  4. The Effect of Vestibular Rehabilitation in the Management of Vestibular Migraine in Adults: A Systematic Review and Meta-Analysis. El Ahdab J, Vilardo M, Ong B, et al. Headache. 2025;. doi:10.1111/head.70002.

  5. Outcome of Vestibular Rehabilitation in Vestibular Migraine. Balci B, Akdal G. Journal of Neurology. 2022;269(12):6246-6253. doi:10.1007/s00415-022-11250-4.

  6. Pharmacological Interventions for Acute Attacks of Vestibular Migraine. Webster KE, Dor A, Galbraith K, et al. The Cochrane Database of Systematic Reviews. 2023;4:CD015322. doi:10.1002/14651858.CD015322.pub2.

  7. Pharmacological Interventions for Prophylaxis of Vestibular Migraine. Webster K, Dor A, Galbraith K, et al. The Cochrane Database of Systematic Reviews. 2023;2023(4):CD015187. doi:10.1002/14651858.CD015187.pub2.

  8. The Effectiveness of Vestibular Rehabilitation in Vestibular Migraine: A Systematic Review. Sfakianaki I, Nikitas C, Kikidis D. Journal of the Association for Research in Otolaryngology : JARO. 2026;:10.1007/s10162-026-01042-2. doi:10.1007/s10162-026-01042-2.