Vestibular migraine and spontaneous vertigo – Migraine Associated Vertigo

Ross Hauser, MD

This article continues and provides further discussion and information on cervical vertigo. Please refer to Cervical Vertigo and Cervicogenic Dizziness for more discussion, patient cases, and treatment options for problems of dizziness.

When people come into our offices with a problem of Vestibular migraine, spontaneous vertigo, or Migraine Associated Vertigo they talk to us about a very long medical journey they have taken that no one can quite understand. This lack of understanding includes family and medical professionals. If their stories are similar to your story, you will know that these people spend a lot of time looking for the triggers that cause the “silent migraine” a headache-free migraine, and the sudden, spontaneous vertigo that comes with it.

Here are some of the stories we have heard from our patients:

My doctor sent me to a nutritionist. We did allergy food testing, which I was sensitive to a few things. I was told no sugars and no caffeine because in addition to the dizziness, I would suffer from sudden onset panic attacks and of course, this whole problem with my health leaves me pretty much exhausted with stress and anxiety. 

I am still on the diet, I think it has helped somewhat, but I still get these symptoms of migraine aura and then dizziness. They even come to me in my dreams. 

I have been on Verapamil, it helps a little. My doctor thinks it would work better if I had symptoms of Meniere’s Disease. I do have a sway to me. 

Treatments for me up until this point have not been successful. Things do not work for me long-term. At this point, I would be grateful if something worked for me short term. As my symptoms got worse I would get more diagnoses and more medications. I started to get confused as to whether my worsening symptoms were the result of side effects from these medications or new manifestations. 

I thank god that I am still somewhat functional and that I have a supportive husband. I am also grateful that these attacks seem to have been less dramatic and less frequent, however, they are still there in the back of my mind. I wish I had answers. 

If this story sounds familiar to you and you are also searching for answers, this article will present one possible answer for you. That your symptoms are being caused by cervical neck instability and physical problems in your cervical spine manifesting themselves in vestibular migraine and spontaneous dizziness.

Article outline:

  • The difficulty in understanding vestibular disorders was demonstrated by researchers.
    • The misdiagnosis in Menière’s disease and vestibular migraine.
    • Misdiagnosis of vestibular migraine is common.
    • “No objective tests, imaging or audiology, have been shown to reliably diagnose this condition.”
  • “Vestibular migraine is the most common cause of spontaneous vertigo but remains poorly understood.”
  • The difference between Vestibular migraines and migraines – Can your doctor tell? Maybe if you are post-menopausal, depressed, motion sick, complaining of imbalance, and of food-triggered headaches.
  • The vestibulo-ocular reflex (VOR).
  • Why vestibulo-ocular reflex may connect other symptoms to Vestibular migraine.
  • Why does the treatment protocol include antidepressants, antiepileptics, beta-blockers, and physical therapy? Some may find this treatment successful. People with neck pain and instability may not.
  • Treatment options.

The difficulty in understanding vestibular disorders was demonstrated by researchers.

The difficulty in understanding vestibular disorders was demonstrated by researchers in June 2021 writing in the Frontiers in Neurology (1)

“Despite the huge progress in the definition and classification of vestibular disorders within the last decade, there are still patients whose recurrent vestibular symptoms cannot be attributed to any of the recognized episodic vestibular syndromes, such as Menière’s disease, vestibular migraine, benign paroxysmal positional vertigo, vestibular paroxysmia, orthostatic vertigo or transient ischemic attack (TIA).”

What the researchers in this study were hoping to provide was a clinical picture of recurrent vestibular symptoms not otherwise specified (or categorized within a diagnosis) and to compare it to Menière’s disease and vestibular migraine. What they suggest is that recurrent vestibular symptoms not otherwise specified (given a diagnostic label) may be a form of diagnosis.

  • Thirty-five patients with recurrent vestibular symptoms not otherwise specified, 150 patients with vestibular migraine or probable vestibular migraine, and 119 patients with Menière’s disease were included in the study.
  • The symptoms of recurrent vestibular symptoms not otherwise specified had been present for 5.4 years on average before inclusion, similar to vestibular migraine and Menière’s disease in this study, suggesting that recurrent vestibular symptoms not otherwise specified are not a transitory state before converting into another diagnosis. (In other words, recurrent vestibular symptoms not otherwise specified are somewhat of a diagnosis itself). Overall, the profile of recurrent vestibular symptoms not otherwise specified vestibular symptoms was more similar to vestibular migraine than Menière’s disease.

The diagnosis of recurrent vestibular symptoms not otherwise specified

The researchers then provided a profile of recurrent vestibular symptoms not otherwise specified:

  • Positional, head-motion, and orthostatic vertigo.
  • In general, vertigo attacks and associated vegetative symptoms (nausea and vomiting) were milder in recurrent vestibular symptoms not otherwise specified than in the other two disorders.
  • Some patients with recurrent vestibular symptoms not otherwise specified described accompanying auditory symptoms (tinnitus: 2.9%, aural fullness, and hearing loss: 5.7% each), migrainous symptoms (photophobia, photophobia, or visual aura in 5.7% each), or non-migrainous headaches (14%), but did not fulfill the diagnostic criteria for Menière’s disease or vestibular migraine.
  • These findings suggest that recurrent vestibular symptoms not otherwise specified is a stable diagnosis over time whose overall clinical presentation is more similar to vestibular migraine than to Menière’s disease. It is more likely to be composed of several disorders including a spectrum of mild or incomplete variants of known vestibular disorders, such as vestibular migraine and Menière’s disease, rather than a single disease entity with distinct pathognomonic features.

The misdiagnosis of Menière’s disease and vestibular migraine

An April 2023 paper in the Journal of Neurology (2) follows this research and suggests vestibular migraine as a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of Menière’s disease. Furthermore, the misdiagnosis of Menière’s disease and vestibular migraine could lead to vestibular migraine patients mistakenly receiving the traumatic treatment protocol designed for Menière’s disease, and sustaining unnecessary damage to the inner ear.

Misdiagnosis of vestibular migraine is common.

Researchers at the University of California, San Francisco, and the University of California, Irvine published a 2022 paper in the journal Current Opinion in Neurology. (3) In this paper they examined vestibular migraine and other cochleovestibular symptoms related to migraine. They noted:

  • Misdiagnosis of vestibular migraine is common. The pathophysiology is currently unknown.
  • Many audiovestibular symptoms have been shown to be associated with migraine, including tinnitus, hearing loss, aural fullness, otalgia, and sinus symptoms.
  • Migraine is also associated with a risk of developing numerous otologic conditions, including Meniere’s disease, vestibular loss, Benign Paroxysmal Positional Vertigo, and sudden sensorineural hearing loss. There is now some evidence that patients may experience fluctuating hearing loss and aural fullness without vertigo in association with migraine, which is called cochlear migraine.

Summary: Migraine can cause a variety of audiological and vestibular symptoms, and further research is required to understand how migraine affects the inner ear.

In October 2022, doctors at the University of California Irvine wrote in the journal Otolaryngologic Clinics of North America (4) migraine headaches frequently coexist with vestibular symptoms such as vertigo, motion sickness, and gait instability. Migraine-related vasospasm can also damage the inner ear, which results in symptoms such as sudden sensorineural hearing loss and resultant tinnitus. The pathophysiology of these symptoms is not yet fully understood, and despite their prevalence, there is no universally approved management. A September 2022 paper in the Frontiers in Neuroscience (5) wrote: “The history of motion sickness is significant in patients with VM and may be a potential suggestive factor for the diagnosis of Vestibular migraine.”

“No objective tests, imaging or audiology, have been shown to reliably diagnose this condition”

This is the introduction to a paper from doctors at the Department of Otolaryngology, George Washington University Medical Faculty Associates. It was published in July 2021 in the journal Otolaryngologic Clinics of North America. (6) If you feel that your doctor does not understand your condition, it may be because your doctor does not understand your diagnosis and why he or she is prescribing medications that may  (hopefully) or may not work.

“Vestibular migraine is one of the most common neurologic causes of vertigo. Symptoms and International Classification of Headache Disorders criteria (see below) are used to diagnose Vestibular migraine because no objective tests, imaging, or audiologist, have been shown to reliably diagnose this condition. Central auditory, peripheral, and central vestibular pathway involvement has been associated with Vestibular migraine. Although the interaction between migraine and other vestibular disorders can be a challenging scenario for diagnosis and treatment, there are data to show that vestibular rehabilitation and a variety of pharmacologic agents improve reported symptoms and vertigo frequency.”

We will discuss pharmacologic treatment further below. Although if you are reading this article, you may, yourself have reached a point where pharmacologic agents are no longer providing relief.

Explanatory note: The International Classification of Headache Disorders criteria calls for possible diagnosis of vestibular migraine when some of the following are present.

  • Migraine and probable migraine
  • Migraine and probable migraine without aura
  • Migraine and probable migraine with aura, Migraine and probable migraine with typical aura.
  • Migraine aura-triggered seizure
  • Typical aura with headache
  • Typical aura without headache
  • Migraine with brainstem aura
  • Hemiplegic migraine (one side pain and especially weakness)
  • Familial (hereditary) hemiplegic migraine (FHM – FHM Types 1,2,3)
  • Sporadic hemiplegic migraine (SHM)
  • Retinal migraine
  • Status migrainous (A migraine lasting more than 72 hours)
  • Persistent aura without infarction
  • Migrainous infarction
  • Possible connections to gastrointestinal problems, Cyclical vomiting syndrome
  • Possible connections to Abdominal migraine, Benign paroxysmal vertigo, Benign paroxysmal torticollis.

“Vestibular migraine is the most common cause of spontaneous vertigo but remains poorly understood.”

Poorly understood is a recurrent theme when it comes to patients with Vestibular migraine and spontaneous vertigo.

Stat Pearls is a publication of the National Center for Biotechnology Information, U.S. National Library of Medicine. In the article Migraine-Associated Vertigo (Vestibular Migraine) (7), Daniel B. Hilton and Carl Shermetaro of McLaren Oakland Hospital write of the complication surrounding the understanding of Vestibular migraine and spontaneous vertigo. (Article Updated July 2021) Again, this may explain why your healthcare providers are looking for answers for you.

  • “Patients explain a sensation of motion when no motion is taking place or an altered sensation with a normal motion to define vertigo. In a vestibular migraine, the sensation is often described as a “to-and-fro” (backward and forward) sensation, and this can complicate diagnosis. Simultaneous headaches do not always accompany the vestibular symptoms, thus making an in-depth history and multi-specialty evaluation pivotal in order to make a diagnosis.”
  • “Current management of a vestibular migraine consists of conventional migraine management as there is currently no accepted specific treatment for this disease. Additionally, convincing a patient of the diagnosis can prove difficult and lead to a delay in treatment or absence of treatment. This is understandable based on the fact that vertiginous symptoms are often asynchronous (happening at the same time) with a headache and maybe a difficult connection for the practitioner or patient to grasp.”

The difference between Vestibular migraines and migraines – Can your doctor tell? Maybe if you are post-menopausal, depressed, motion sick, complaining of imbalance, and food-triggered headaches.

A June 2021 paper in the Journal of Neurology (8) comes from the Department of Neuroscience, Institute of Health Sciences, Dokuz Eylül University in Turkey. Here are the summary points:

  • Vestibular migraine is one of the most common causes of vertigo in clinical practice but it is not always easy to make the correct diagnosis.
  • The researchers found that Vestibular migraine patients were more likely than migraine patients to be female, post-menopausal, depressed, motion sick, complaining of imbalance, and of food-triggered headaches. In contrast, migraine patients were more likely than Vestibular migraine patients to have severe headaches, and these can be triggered by certain odors and by noise.

The vestibulo-ocular reflex (VOR)

Another study published in October 2019, led by researchers at Massachusetts Eye and Ear Infirmary, Harvard Medical School, and Ohio State University also examined Vestibular migraine as one of the most common causes of spontaneous vertigo and why this problem remains poorly understood. The study was published in Scientific Reports (9).

Here are the learning points:

  • “Vestibular migraine is the most common cause of spontaneous vertigo but remains poorly understood.”
  • The researchers investigated the hypothesis that central vestibular pathways (dysfunctions of the body’s system to maintain balance) are sensitized (heightened) in Vestibular migraines by the vestibulo-ocular reflex (VOR) and vestibular and headache symptom severity.

We are going to move away from this research for some brief understanding notes and then we will return:

  • The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment).
    • It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism.
      • As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.

Why vestibulo-ocular reflex may connect other symptoms to Vestibular migraine

A May 2021 paper in the journal Otology & Neurotology (10) found a significantly higher prevalence of enhanced vestibulo-ocular reflex responses in patients with Menière’s disease, central origin vertigo, otosclerosis (abnormal bone growth in the ear), and vestibular migraine than in those with other neurotologic diseases and controls. This study found that enhanced vestibulo-ocular reflexes are not pathognomonic (indicative) of hydrops-related diseases and the diagnosis should not solely be based on these and instead take into context other clinical and examination findings. In other words, look at the other symptoms and conditions.

A March 2023 paper from Pisa University Hospital in Italy published in the Journal of clinical medicine (11) suggests that the presence of Hippus or “Pupillary nystagmus”  a well-known phenomenon characterized by cycles of dilation and narrowing of the pupil under constant lighting conditions may be a predictor and diagnostic supportive symptom of vestibular migraine.

In this study, 30 patients with dizziness suffering from vestibular migraine were evaluated for the presence of pupillary nystagmus and compared with the results obtained in a group of 50 patients complaining of dizziness that was not migraine-related.

Among the 30 vestibular migraine patients, 28 had positive pupillary nystagmus findings. Among the 50 non-migraineurs dizzy patients, three had pupillary nystagmus, while the remaining 47 did not.

What are we seeing in this image?

The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. As human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.

The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. In human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady," to prevent motion from creating dizziness or sway.

Returning to the study

  • Vestibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting the sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)
  • The researchers suggest a pathogenic model where vestibular symptoms emanate from the vestibular nuclei, (the cranial center point for the vestibular nerve) which are sensitized by migraine-related brainstem regions and simultaneously suppressed by inhibitory feedback from the cerebellar nodulus and uvula, the site of canal-otolith integration.

The suggestion is simply, something is happening to the vestibular nerve which is overly sensitized to pain by the reaction of something happening to the brainstem, and the process is further sent into panic by a dysregulation of the function of the balance mechanism in the ear. This was also suggested in a March 2023 study (12) which examined autonomic neuropathy (damaged signals or communications from the nerves of the autonomic system – heart rate, blood pressure, respiration, digestion, etc.,) during vestibular migraine interphase features (vertigo, light sensitivity or photophobia) with imbalance between sympathetic and parasympathetic nervous system with the observation that sympathetic nerve function is mainly impaired.

What are we seeing in this image? Vestibular migraine patients were abnormally sensitive to roll tilt

It’s an ear problem, not a Ménière’s disease problem. Vestibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting the sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)

It's an ear problem, not a Ménière's disease problem. estibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere's Disease type problem.)

Why does the treatment protocol include antidepressants, antiepileptics, beta-blockers, and physical therapy? Some may find this treatment successful. People with neck pain and instability may not.

As we are quick to point out. Many people do well with many treatments for vestibular migraine and spontaneous vertigo. People who do well with medications are typically not the people we see in our office. Medications do not work for everyone.

Let’s examine a May 2020 study (13) from the Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina. In this study, researchers sought to identify patient factors that influence response to therapy in patients with vestibular migraines. In other words, what could make the treatment work better, what factors would predispose a patient to a less-than-optimal response to treatment?

  • 47 patients were evaluated for the treatment of definite vestibular migraine
  • Interventions: A protocol of antidepressants, antiepileptics, beta-blockers, and vestibular rehabilitation. Patients failing initial therapy received botulinum toxin per the PREEMPT (before the migraines start) protocol. Vestibular rehabilitation (physical therapy to improve balance and problems related to dizziness.)

What happened to the 47 patients?

  • Of the 47 patients who underwent therapy for vestibular migraine. This population had a significant dizziness handicap inventory (a measuring score) reduction with therapy.
  • This worked especially better for women, patients with comorbid benign paroxysmal positional vertigo, and high initial dizziness handicap inventory was significantly associated with a greater reduction in dizziness handicap inventory scores.

Neck pain and oscillopsia did not respond as well

  • Conversely, cervicalgia and oscillopsia were significantly associated with a lower reduction in dizziness handicap inventory scores.

Traditional treatment options for Vestibular migraine

Vestibular physical therapy

A January 2020 paper in the journal Cephalalgia (14) gives an overview of treatment options. Here is a summary of some of the points of that paper.

The uncertainties surrounding vestibular migraine diagnosis over the last few decades have also limited advances in treatment. In general, vestibular migraine patients can be managed with lifestyle modification, dietary adjustments, medications, vestibular physical therapy, and activities that can enhance the perception of spatial orientation, such as ping-pong or dancing.

As a key intervention, dietary adjustment and eliminating triggers such as red wine, aged cheeses, artificial sweeteners, processed meats, chocolate, caffeine, MSG, and alcohol are found to be effective in reducing symptoms

Like other migraine subtypes, medical treatment in vestibular migraine patients aims to reduce the frequency and severity of symptoms. . .These medications are mainly antihypertensives, antidepressants, and antiepileptics with general applications in migraine prevention.

Vestibular rehabilitation has been used to alleviate symptoms and promote recovery in vestibular migraine patients, as in other vestibular disorders. Although most studies show that focused vestibular rehabilitation benefits patients, no randomized control study has evaluated the efficacy of vestibular physical therapy in vestibular migraine patients.

Botulinum toxin A application

A December 2022 paper (15) suggests “botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. . . ”

Researchers assessed the effectiveness of botulinum toxin A application and botulinum toxin A application combined with oral medication type (propranolol, flunarizine, and amitriptyline) on vestibular symptoms, headache severity, and attack frequency for vestibular migraine patients.

  • Sixty patients with vestibular migraine were enrolled.
  • Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B- group).
  • Vestibular migraine attack frequencies in the last three months were also evaluated.

Chinese Medicine 

An April 2023 review study in the Journal of clinical neuroscience (16) suggests traditional Chinese medicine has a unique advantage in treating vestibular migraine. However, as there is no unified clinical treatment method the authors of this study sought to provide evidence-based medical evidence by systematically evaluating the clinical efficacy of oral traditional Chinese medicine in treating vestibular migraine.

In reviewing 21 previously published articles which included 1650 patients in total 828 of them were in the therapy group and 822 of them were in the control group. “Among the literature included in this study, the most frequently used traditional Chinese medicines are Chuanxiong and Gegen (common herbs and supplements).”

According to this study, the therapy group outperformed the control group in terms of the total efficiency rate and traditional Chinese medicine syndrome score . . .The number of vertigo attacks and the duration of each vertigo decreased compared to the control group. The researchers concluded: “The oral traditional Chinese medicine is an effective way for vestibular migraine, which would help with the clinical symptoms, reduce the TCM syndrome score, decrease the number of vertigo attacks and the duration of each vertigo, and improve the life quality of patients.”

Are neck pain and cervical spine instability a possible cause of your vestibular migraine and spontaneous vertigo – migraine-associated vertigo?

We suggest one possible answer for this, not the only one. We feel an examination of cervical spine instability may lead to an answer.

When there is pressure on the brain stem, and this pressure can be exerted by hypermobility of the cervical spine vertebrae, this can result in health problems or diseases of the brainstem which can result in abnormalities in the function of cranial nerves. These would be the problems we spoke about earlier surrounding visual disturbances, pupil abnormalities, vestibular and headache symptom severity, hearing problems, vertigo, and swallowing difficulty, among other challenges. In our case, we may explore what is happening throughout the cervical spine with attention to cervical vertebrae where Cranial Nerve VIII (Vestibulocochlear nerve) is comprised of the cochlear nerve (hearing) and the vestibular nerve (sense of space, balance) moves from the ear to the brain stem.

Regenerative Medicine Injections

Prolotherapy is an injection technique that stimulates the repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing Vestibular migraine and spontaneous vertigo), and cause other symptoms associated with joint instability, including cervical instability.

Treating cervical ligaments – published research from Caring Medical

In our 2014 research headed by Danielle R. Steilen-Matias, PA-C, We also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.

Treating and stabilizing the cervical ligaments can alleviate the problems of  Vestibular migraine and spontaneous vertigo by preventing excessive abnormal vertebrae movement, the development or advancement of cervical osteoarthritis, and the myriad of problematic symptoms they cause.

If this article has helped you understand the problems of cervical vertigo and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

Continue with your research with these articles:

References

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