Dizziness and Migraine
Dizziness is one of the most common complaints in medicine and
is reported to affect 20%-30% of the general population. Migraine
is also a very common disorder, with prevalence in the general
population ranging from 6%-20% in men and 17%-29% in women. Thus,
3%-4% of the population can be expected to experience both
dizziness and migraine. In reality, however, the cooccurrence of
symptoms is much higher than that. Specifically, vertigo, which
is the sensation of perceived motion without actually moving, is
reported by up to one third of people who have migraine, and
general dizziness or unsteadiness is reported by up to three
quarters of all patients with migraine.
Unfortunately, although migraine is a common cause of
dizziness, it is often not correctly diagnosed until years after
the patient initially seeks medical care for complaints of
dizziness. The delay is due, in part, to the fact that most
patients and many physicians think of migraine only in terms of
headache, when it is actually an organic neurological syndrome.
The result is that even in patients with headaches, migraine is
often misdiagnosed as sinus headache or tension-type headache.
Less than half of all migraine sufferers have received a
diagnosis of migraine from their health care provider.
Furthermore, vertigo is not included in the International
Headache Society classification system as a symptom of migraine
except as a part of basilar migraine, so most patients who have
migrainous vertigo (MV) cannot be classified using the existing
criteria. Recently, diagnostic criteria have been proposed that
separate definite MV from probable MV and that conceptualize MV
as an episodic vestibular disorder.
Migraine is now believed to be a genetically based
neurological disorder in which certain triggers start a series of
events including functional changes in the trigeminal nerve
system and imbalances in brain chemicals, such as serotonin, that
regulate pain. As a result, the trigeminal nerve releases
chemicals that irritate and cause swelling of blood vessels on
the surface of the brain, sending pain signals to the brainstem.
MV may occur at any age and has a female preponderance with a
probable autosomal dominant inheritance pattern with decreased
penetrance in men. Typically, migraine begins earlier in life
than does MV, and it is not unusual for vertigo to replace
headaches in women around menopause.
Various factors have been identified as being migraine
triggers, including foods, stress, hormones, physical activity,
sensory stimuli, and environmental factors. Individuals with
migraine are often aware of the things that serve as triggers for
them, since part of migraine management is avoidance of triggers.
Some of the more common triggers are detailed below:
- Diet - Alcohol (especially red wine), aged cheeses,
chocolate, aspartame, caffeine, and monosodium glutamate (MSG),
as well as skipping meals or fasting, can trigger
- Stress - Stressful situations or relaxation after stress
can trigger migraine.
- Hormonal changes - Natural hormonal changes such as during
the menstrual cycle or during pregnancy and menopause, as well
as hormonal medications such as contraceptives or hormone
replacement therapy, may worsen migraine.
- Physical activity - Heavy exertion or changes in sleep
pattern can initiate migraine.
- Sensory stimuli - Bright lights, sun glare, and unusual
smells, even if pleasant, could trigger migraine.
- Environmental factors - Changes in season, weather,
altitude, or barometric pressure can prompt migraine.
Like migraine and many vestibular disorders, MV is diagnosed
primarily on the basis of history. Specifically, risk factors for
MV include family history or remote personal history of migraine;
long history of motion intolerance with tendency toward motion
sickness; visual motion sensitivity where visually challenging
environments, such as supermarket aisles, feel uncomfortable;
dislike of bright lights (photophobia); dislike of loud sounds
(phonophobia); and increased tendency for nausea. In fact, the
proposed criteria for both definite and probable MV include the
combination of episodic vestibular symptoms of at least moderate
severity coupled with a personal history of migraine and/or a
relationship between the vestibular symptoms and some aspect of
migraine (e.g., triggers, response to medications). Additionally,
the criteria specify that other causes have been ruled out by
Dizziness due to migraine can present in different forms.
Patients may actually feel vertigo, they may just feel
lightheaded and unsteady, or they may simply feel that their head
is not right. These sensations may occur individually or in
combination, and can last seconds, minutes, hours, or days. The
duration of symptoms typically varies across episodes. With MV,
dizziness is not usually associated with auditory symptoms such
as fluctuating hearing loss or unilateral tinnitus. In addition,
it is important to realize that there is not necessarily a timing
relationship between headaches and dizziness. In fact, as
mentioned earlier, headache may be absent.
Because dizziness can be caused by numerous factors, reaching
a correct diagnosis can be quite challenging. The single most
important element in reaching a correct diagnosis is obtaining an
accurate history. The diagnosis of MV is usually made when the
patient has the traditional risk factors for migraine and the
dizziness fits the characteristics mentioned above. Other
disorders can usually be ruled out by accurate analysis of the
history given by the patient. Although MV is often confused with
Meniere's disease (MD), the diagnosis of MD should be limited
to individuals experiencing fluctuating hearing loss, tinnitus,
and aural fullness in one ear together with vertigo lasting less
than 24 hours. It should be noted that vestibular function
testing can be abnormal in about 25% of patients with MV. Other
potential diagnoses (e.g., vestibular schwannoma) should be ruled
out by the appropriate imaging studies such as MRI.
Treatment of migraine-related dizziness is usually
accomplished by migraine prevention. Medications to stop the
progression of headaches do not have an effect on the dizziness.
Migraine prevention should be a multitiered approach. Keeping a
headache diary to record events that may contribute to the
headache can be helpful. Avoiding known trigger factors is also
helpful in managing the migraine. Management includes a healthy
lifestyle with regular exercise and balanced meals, in addition
to healthy sleep habits. Medications can be used if these
measures alone are not enough. Most preventive migraine
medications were first developed to treat other disorders such as
high blood pressure, depression, or seizures. Although the
mechanism of action of these medications is not completely
understood, they are thought to work by affecting the balance of
certain chemicals in the brain. The major groups of medication
used for migraine prevention include beta-blockers, calcium
channel blockers, tricyclic antidepressants, and anti-epileptic
(anti-seizure) medicines. Each patient with migraine is unique,
and not every medication will work for every patient. In
addition, since each of these medications has its own side
effects as well as possible drug interactions, the choice of
medication should be discussed carefully with the patient's
primary health care provider.
Jaynee Handelsman, PhD
Assistant Director, Vestibular Testing Center
University of Michigan Health System
Hussam El-Kashlan, MD
Medical Director, Vestibular Testing Center
Department of Otolaryngology
University of Michigan Health System
Harnor, H., Hirvonen, T., Kaunisto, M. A., Aalto, H., Levo,
H., Isotalo, E., et al. (2003). Subclinical vestibulocerebellar
dysfunction in migraine with and without aura.
Neurology, 61, 1748-1752.
Lempert, T., & Neuhauser, H. (2005). Migrainous vertigo.
Neurologic Clinics, 23, 715-730.
Neuhauser, H. K., & Lempert, T. (2005). Diagnostic
criteria for migrainous vertigo.
Acta Oto-Laryngologica, 125, 1247-1248.
Neuhauser, H., Leopold, M., von Brevern, M., Arnold, G., &
Lempert, T. (2001) The interrelations of migraine, vertigo, and
Neurology, 56, 436-441.
Neuhauser, H., von Brevern, M., Radtke, A., Lezius, F.,
Feldmann, M., Ziese, T., & Lempert, T. (2005) Epidemiology of
vestibular vertigo: A neurotologic survey of the general
Neurology, 65, 898-904.
This article first appeared in the Vol. 5, No. 3, July/August
2006 issue of