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Understanding the Stages of Vestibular Migraine

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It’s time to rebrand vestibular migraine (and in doing so, we’ll try our best to lay off the dizziness puns).

Often, people think of “migraine” as synonymous with “headache,” but vestibular migraine is a prime example of brain pain not being a required symptom of a migraine attack. So what does that mean for someone who lives with vestibular migraine? What symptoms do they experience? And can people with chronic or episodic migraine experience balance disturbances, too?

What Is Vestibular Migraine?

Vestibular migraine is a distinctive migraine disorder that combines elements of vestibular dysfunction with hallmark migraine symptoms. (If you’re new to learning about the vestibular system, here’s a great overview by the Vestibular Disorders Association.) This neurological disease primarily manifests as recurrent episodes of dizziness, vertigo, and unsteadiness, and can be accompanied by pulsating headaches — but not always.

Symptoms and Diagnosis

Accurate diagnosis of vestibular migraine hinges on a thorough understanding of its unique symptoms. These include not only the hallmark features of vestibular dysfunction like vertigo and balance issues, but also specific headache patterns that differentiate it from other migraine subtypes. A physical examination by a health care provider specializing in identifying vestibular disorders is recommended for a diagnosis. This examination is designed to uncover subtle signs that may not be apparent in everyday activities, such as cranial nerve function, eye movements, gait, and coordination.

There are also specific diagnostic procedures to refine the diagnosis further. These may include tests of vestibular function, such as the Dix-Hallpike maneuver to assess for benign paroxysmal positional vertigo (BPPV), and vestibular-evoked myogenic potentials (VEMPs) to evaluate the function of certain inner ear structures. Additionally, imaging studies like magnetic resonance imaging (MRI) may be ordered to rule out other underlying causes of vestibular symptoms.

Triggers and Risk Factors

Triggers and risk factors play a pivotal role in the onset and exacerbation of vestibular migraine. Identifying these triggers, which can range from stress and hormonal changes, to specific foods and environmental stimuli, empowers patients to manage their condition proactively. Additionally, understanding demographic and lifestyle risk factors provides valuable insights into the predisposition to vestibular migraine.

The Stages of Vestibular Migraine

Like most migraine subtypes, vestibular migraine is not an outlier when it comes to manifesting in stages. Understanding the stages and how to identify them can lead to a more accurate diagnosis and a more personalized treatment plan.

Prodrome Phase

The prodrome phase serves as an early warning system, signaling the onset of an impending attack. Here are some signs to watch out for:

  • Mood and behavior changes: One of the primary indicators during the prodrome phase is a shift in mood and behavior. This may manifest as heightened irritability, mood swings, or changes in emotional states. People may notice themselves becoming more sensitive or easily agitated.
  • Physical sensations: Some patients report experiencing heightened sensitivity to light, sound, or touch. Others may notice changes in appetite, sleep patterns, or energy levels.
  • Cognitive variations: Cognitive functions can be affected during the prodrome phase. This may include difficulty concentrating, lapses in memory, or a feeling of mental fogginess (also known as brain fog).
  • Fatigue: A notable symptom of the prodrome phase is increased fatigue. People may feel more tired or lethargic than usual, which can be a significant cue of an impending migraine.
  • Food cravings or aversions: Changes in appetite, including specific cravings or aversions to certain foods, can indicate the prodrome phase.
  • Duration of the prodrome phase: The duration of the prodrome phase can vary widely among individuals. Some may experience these early warning signs a few hours before an attack, while others may notice them up to several days in advance.

Aura Phase

Not all individuals with vestibular migraine experience an aura, but for those who do, it can be a distinctive feature that precedes the headache phase. Recognizing its presence could help prepare for subsequent stages of the migraine. This may involve finding a quiet, dimly lit space, having necessary medications or comfort items readily available, and notifying others if assistance may be needed. Here’s what you should look out for:

  • Reversible sensory disturbances: These can manifest in various forms, such as tingling or numbness in the extremities, altered perception of touch, or even temporary disruptions in speech or language comprehension.
  • Visual symptoms: Among the most common manifestations of aura are visual disturbances. These can range from flickering lights or zigzag patterns in the visual field to temporary vision loss in one eye.
  • Temporal relationship with headache phase: Timeline matters, as the aura phase typically precedes or accompanies the headache phase of the migraine.
  • Duration and variability: The duration and specific symptoms of the aura phase can vary widely. Some may experience relatively brief episodes, while others may have more prolonged or complex ones.

Headache Phase

A specific set of migraine pain patterns characterizes the headache phase of vestibular migraine. These headaches are typically pulsating in nature and are often accompanied by nausea or queasiness, sensitivity to light and sound, and sometimes vomiting. In some cases, the intensity of the headache can lead to vomiting.

Resolution Phase

As the acute attack subsides, some symptoms may linger. This phase, known as the resolution phase, can include residual dizziness, fatigue, and cognitive fog. To ease recovery, implementing self-care measures during this stage is paramount.

Postdrome Phase

The postdrome phase — sometimes known as the “migraine hangover” — entails the aftermath of an attack. Common post-attack symptoms may include fatigue, difficulty concentrating, and mood changes. The trickiest part is that these symptoms can persist for hours or even days after the main attack, which busts the misconception that a migraine is simply “get through the pain and then it’s over.” (Our favorite postdrome hack? Electrolytes!)

Managing Each Stage of Vestibular Migraine

Effectively managing vestibular migraine involves tailored strategies for each stage. This may encompass a combination of medication, lifestyle adjustments, and vestibular therapy to alleviate symptoms and improve quality of life. Consider starting here:

  • Early intervention with medication: In the prodrome phase, early recognition of warning signs can give patients an ideal window to take prescribed medications. These medications can soften the severity of the impending attack before it starts.
  • Aura phase management: For individuals who experience the aura phase, understanding its sensory manifestations enables them to take appropriate measures. This may include finding a quiet, comfortable space and engaging in relaxation techniques to help ease any associated anxiety. (In case you needed to hear it, the mental health component of physical symptoms like disorientation and wobbliness is valid. You are not alone.)
  • Pain relief and symptom management during the headache phase: A targeted approach to pain relief is key in the headache phase. Medications designed explicitly for migraine relief can be taken, along with measures to address associated symptoms like nausea and sensitivity to light and sound.
  • Post-attack care and recovery: As the acute attack subsides, attention turns to the resolution and postdrome phases. Engaging in self-care practices, such as prioritizing rest, maintaining hydration, and engaging in gentle movement, aids in the recovery process.
  • Long-term lifestyle adjustments: A sustained management plan for vestibular migraine necessitates lifestyle modifications. This may involve adopting stress management techniques, incorporating regular exercise, ensuring sufficient and restorative sleep, and maintaining a balanced and nourishing diet.
  • Lifestyle modifications and preventative measures: Strategies such as stress management, regular exercise, creating and sticking to routines, adequate sleep, consistent hydration, and balanced nutrition can play a pivotal role.
  • Identifying and avoiding triggers: A crucial aspect of managing vestibular migraine involves identifying and mitigating triggers. This requires self-awareness and may entail avoiding specific foods, environments, or activities that provoke episodes.

Vestibular Therapy for Enhanced Stability

Vestibular therapy, a specialized form of physical therapy, can be invaluable in addressing balance issues and enhancing stability. Here’s a more detailed exploration of it:

  • Focused expertise: Vestibular therapists are highly skilled professionals with specialized training in addressing vestibular system disorders. Their expertise enables them to design interventions that cater to the unique needs of individuals experiencing vestibular migraine.
  • Comprehensive assessment: The process begins with thoroughly evaluating the person’s vestibular function. This assessment helps pinpoint specific areas of challenge and provides a baseline from which progress can be measured.
  • Targeted exercises: Vestibular therapists develop a customized exercise regimen based on the assessment findings. These exercises are selected to engage and stimulate the vestibular system, progressively improving its functionality.
  • Adaptation and habituation techniques: Vestibular therapy often incorporates exercises that involve controlled exposure to specific movements or stimuli that may trigger symptoms. Through repeated exposure and gradual habituation, individuals can desensitize their vestibular system to these triggers, ultimately reducing symptom severity.
  • Gaze stabilization: This technique improves an individual’s ability to maintain a steady gaze during head movements. By training the eyes to remain fixed on a target while the head moves, vestibular therapy enhances visual stability and reduces symptoms of dizziness or vertigo.
  • Balance and coordination exercises: Vestibular therapy includes various activities to challenge balance and coordination. These exercises may involve standing on unstable surfaces, navigating obstacle courses, or performing specific movements to enhance proprioception.
  • Recovery and functional integration: As progress is made, vestibular therapy focuses on incorporating improved vestibular function into daily activities. This phase of treatment emphasizes practical application, ensuring that newfound stability translates to real-world scenarios.
  • Gradual progression: Vestibular therapy is tailored to the individual’s pace and capabilities. Exercises are introduced and progressed in a controlled manner to maximize benefits while minimizing discomfort or exacerbation of symptoms.
  • Patient education and empowerment: Throughout vestibular therapy, individuals are educated about their condition and provided with tools and techniques for self-management.

Treatment Options During an Attack

During a vestibular migraine attack, having a well-informed understanding of available treatment options can make a profound difference in alleviating symptoms. Here are five options that may become a part of your treatment management plan:

  • Acute medications: Specific medications are tailored to provide relief during a vestibular migraine attack. These medications are designed to target the underlying mechanisms of the migraine, alleviating symptoms such as pain, nausea, and sensory disturbances.
  • Triptans: Triptans are a class of medications commonly used for migraine relief. They work by narrowing blood vessels in the brain and reducing inflammation, effectively relieving migraine pain and associated symptoms.
  • Anti-nausea medications: For individuals experiencing nausea or vomiting during a vestibular migraine attack, antiemetic medications can provide significant relief by alleviating gastric distress.
  • Pain relievers: Over-the-counter pain relievers, such as ibuprofen or acetaminophen, may be effective for some individuals in managing mild to moderate migraine pain.
  • Prescription medications: In cases of severe or refractory vestibular migraine, health care providers may prescribe specific medications that target the unique characteristics of the condition.

When to See a Doctor

Recognizing the signs that may warrant a doctor’s visit is essential for timely intervention. Delaying professional help can lead to potential complications when left untreated. Here are some changes to look out for:

  • Changes in attack frequency: If there is a notable shift in the frequency of vestibular migraine attacks, particularly if they become more frequent, consult a health care provider for further evaluation.
  • Increased attack intensity: A significant escalation in the intensity of vestibular migraine attacks can signal the need for medical attention. This includes episodes that are notably more severe than usual or attacks that present with new, alarming symptoms.
  • Altered nature of attacks: Any substantial changes in the nature or characteristics of vestibular migraine attacks should be promptly discussed with a health care provider. This may include new or atypical symptoms that deviate from the individual’s usual experience.
  • Persistent or prolonged symptoms: If symptoms persist for an extended period or if there is a prolonged postdrome phase following an attack, seek medical advice.
  • Concerns about medication efficacy: If prescribed medications are proving ineffective in managing vestibular migraine symptoms, potential adjustments may need to be made to the current treatment plan.
  • Impact on daily functioning: If vestibular migraine attacks significantly disrupt daily activities, work, or personal life, medical intervention is recommended.

Getty image by Vahit Ozalp

Originally published: November 13, 2023
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