Vestibular migraine is a leading yet often overlooked cause of recurring vertigo and dizziness. This guide explains the key symptoms, how it differs from other balance disorders, and the treatment options available in the UK to help manage episodes effectively.
If you have spent years moving between GPs, ENT clinics and neurologists, with scans that come back normal and no clear answer, vestibular migraine is one of the conditions to rule out. It is now considered the most common cause of repeated, unexplained vertigo in adults. It is also one of the most frequently missed diagnoses in both neurology and ear, nose and throat (ENT) practice.
The reason is simple: vestibular migraine often does not look the way people expect migraine to look. The headache may be mild, may arrive after the dizziness has settled, or may not appear at all.
This guide walks through what vestibular migraine is, how it is diagnosed in the UK, what treatment looks like, and the things that most often delay a diagnosis.
What Is Vestibular Migraine?
Vestibular migraine is a neurological condition where the migraine process produces recurring balance symptoms. The most common are vertigo (a spinning or moving sensation), dizziness, unsteadiness and sensitivity to motion. These balance symptoms are caused by the migraine itself, not by a separate inner ear problem.
Formal diagnostic criteria were agreed upon in 2012 by a joint committee of the Bárány Society and the International Headache Society, and updated by consensus in 2021. The condition appears in the International Classification of Headache Disorders. Before these criteria existed, the same condition went by several names: migrainous vertigo, migraine-associated vertigo and migraine-related vestibulopathy. Vestibular migraine is the term now used across specialist UK and international practice.
How it differs from other causes of vertigo
Vestibular migraine can be hard to tell apart from other vestibular conditions. The closest mimics are Ménière’s disease and BPPV, and it is often misdiagnosed as either.
The main differences:
- Unlike BPPV, vestibular migraine is not triggered by specific head positions. Episodes also last much longer than the brief seconds of BPPV spinning.
- Unlike Ménière’s disease, hearing is usually unaffected. Tinnitus or a feeling of fullness in the ear are not a reliable feature.
- Unlike vestibular neuritis, episodes come and go repeatedly rather than being one prolonged attack.
In real clinical practice, these distinctions are not always clean. Vestibular migraine, Ménière’s disease and BPPV can all coexist in the same patient, which is part of why it gets missed for so long.
How Common Is Vestibular Migraine?
Vestibular migraine affects more people than is generally recognised. Lifetime prevalence in the general population is around 1 in 100. The one-year prevalence is just under that, at around 9 in every 1,000 adults.
Among people who already have a migraine diagnosis, the figures are much higher. A large hospital-based study found that around 1 in 10 migraine patients also had vestibular migraine. NHS Lanarkshire’s vestibular service reports that up to 4 in 10 people with migraine experience some form of vestibular symptoms during attacks. Vestibular migraine is not a rare edge case. It is one of the more common ways migraine actually presents.
Women are affected more often than men. A US population-based survey found women made up around 6 in 10 of those affected, with a mean age of around 40 years. A 2024 review from King’s College London described two distinct peaks of onset in women, likely linked to hormonal changes at different stages of life, particularly around perimenopause.
What Causes Vestibular Migraine?
Researchers do not yet have a complete picture of how migraine produces balance symptoms. The strongest evidence points to the way the brain processes sensory information being temporarily disrupted during an attack.
One of the leading explanations involves a protein called calcitonin gene-related peptide (CGRP), which is released during a migraine. CGRP is active in both the pain pathways and the balance pathways of the brain. That overlap may be why migraine can produce vertigo as readily as it produces headache. CGRP has also become an important treatment target, with newer medications that block it now being tested in vestibular migraine specifically.
Other contributing factors include reduced blood flow to the inner ear during attacks and waves of electrical activity spreading across the brain (called cortical spreading depression). The brain’s balance centres can also become oversensitive to normal input over time. Brain imaging studies in people with vestibular migraine have shown differences in activity and connectivity between brain regions. This supports the picture of a sensory processing problem rather than a structural problem with the inner ear.
Triggers and risk factors
Vestibular migraine shares most triggers with migraine generally. The common ones are:
- Hormonal changes (particularly around periods and perimenopause)
- Poor or irregular sleep
- Stress, or the dip after stress (the “weekend migraine”)
- Dehydration and skipped meals
- Certain foods (often aged cheese, red wine, processed meats, but this varies)
- Sudden changes in routine, weather or barometric pressure
People with vestibular migraine are also far more likely to have had motion sickness throughout their lives, often well before the vertigo episodes began. One study of 131 patients found that around 6 in 10 reported lifelong motion sensitivity. If you have always struggled in cars, on boats, on swings or with funfair rides, that history matters and is worth telling a specialist.
A family history of migraine is common. Anxiety and depression appear together with vestibular migraine more often than chance would predict, though the relationship between them runs in both directions and is still being studied.
What the Symptoms Feel Like
Vestibular migraine symptoms vary between people. They also vary in the same person between attacks. There is no single pattern that fits everyone, which is one reason this condition is so often overlooked.
An episode can involve any of the following:
- Spontaneous vertigo – a spinning or rocking sensation that comes on without any head movement
- Positional vertigo – dizziness triggered by changing position or moving the head
- Visual vertigo – disorientation triggered by busy supermarkets, scrolling on a phone, fast-moving traffic or patterned floors
- Head-motion intolerance – dizziness or nausea when turning the head normally
- Unsteadiness – a feeling of being off-balance without spinning
What happens during and between attacks
Episodes last anywhere from five minutes to 72 hours. Most settle within an hour or two. During an attack, some people have a headache, some have none, and some find the headache only arrives after the vertigo has eased. Attacks can also bring sensitivity to light or sound, visual disturbances (such as flickering or blind spots), nausea and a strong urge to lie down somewhere quiet and dark.
Between attacks, some people feel completely well. Others have a constant low-level unsteadiness, motion sensitivity, or discomfort in busy visual environments that never quite goes away. This in-between layer of symptoms can overlap with PPPD (persistent postural-perceptual dizziness), which complicates the picture.
There is one timing pattern worth knowing. In around 7 in 10 people with vestibular migraine, the headaches came first, often years earlier. If you have a long history of migraine and later develop unexplained vertigo episodes, that sequence is a strong clue.
How Vestibular Migraine Is Diagnosed
Vestibular migraine is diagnosed clinically. That means it is diagnosed from the pattern of symptoms, the history of migraine and how the two relate to each other. There is no blood test, hearing test or scan that confirms it. Balance tests carried out between attacks are often completely normal, which sometimes leads people to be told nothing is wrong.
The diagnostic criteria
The 2021 international consensus criteria require all of the following for a definite diagnosis:
- At least five episodes of moderate or severe vestibular symptoms lasting between five minutes and 72 hours
- A current or previous history of migraine, with or without visual aura
- Migraine features during at least half of vestibular episodes – a one-sided throbbing headache, sensitivity to light and sound, or visual disturbances
- No better explanation from another vestibular or headache condition
A separate category of probable vestibular migraine exists for people who do not quite meet all four criteria but have a strongly suggestive picture. This is a clinically useful diagnosis and treatment can begin on this basis.
Why is this diagnosis so often missed?
A 2024 review described vestibular migraine as consistently missed across GP, headache and specialist vestibular services. The most common reasons are:
- Episodes happen without a headache, so clinicians focus on the ear rather than migraine
- Tests between attacks are normal, giving the false impression that there is nothing wrong
- Symptoms overlap with Ménière’s, BPPV and PPPD, and these conditions can all coexist
- The same person describes attacks differently each time, which can make the history seem inconsistent
The most reliable route to a clear answer is a specialist assessment that takes both the vestibular history and the migraine history together, rather than treating them as separate problems handled by separate teams.
Tests in specialist practice
In an experienced vestibular clinic, a small number of vestibular function tests may be carried out. These are not used to prove vestibular migraine, since results can be normal between attacks. They are used to rule out other conditions (such as Ménière’s disease, SSCD or vestibular neuritis) and to look for any subtle, longer-standing changes. Tests used include the video head impulse test (vHIT), caloric testing and detailed hearing assessment.
Vestibular Migraine Treatment in the UK
Treatment falls into two areas: managing symptoms during an attack, and taking regular preventive treatment to reduce how often attacks happen.
It is honest to acknowledge that the evidence base for vestibular migraine specifically is still limited. There are no large, high-quality clinical trials specific to this condition. Most treatment is adapted from what works in migraine generally, and most specialists agree this is reasonable given the shared underlying mechanisms.
Acute treatment during an attack
The aim is to ease the vertigo and the nausea quickly. Medications used in UK practice include:
- Anti-sickness drugs (such as prochlorperazine or metoclopramide)
- Antihistamines (such as cinnarizine) for short-term symptom relief
- Triptans if a headache is part of the attack – evidence in vestibular migraine specifically is mixed, but they are widely used given their established role in migraine
- Anti-inflammatory painkillers (such as ibuprofen or naproxen) for the headache element
- Short-term sedatives for severe episodes, used sparingly
Balance-suppressing medications can help during a bad attack but should not be taken long term. They slow the brain’s ability to recalibrate between episodes, much the same issue as with vestibular neuritis.
Preventive treatment
When attacks are frequent or seriously disruptive, regular preventive medication is worth considering. Options drawn from migraine prevention include:
- Beta-blockers such as propranolol
- Tricyclic antidepressants such as amitriptyline or nortriptyline (used at low doses for migraine prevention, not depression)
- SNRIs such as venlafaxine
- Anti-epileptic medications such as topiramate
- Blood pressure medications such as candesartan
- Calcium channel blockers such as flunarizine – not available through NHS GPs, but obtainable through some headache clinics
A review of 13 different migraine preventives in vestibular migraine found that all produced some improvement, but the differences between studies make it impossible to name one as clearly best. In our clinic, the choice of preventive measures is usually guided by what other conditions a patient has. Propranolol is often a good fit when anxiety is also present. Amitriptyline is helpful when poor sleep is a major trigger.
CGRP-targeting medications
One of the more interesting recent developments is the use of medications that block CGRP, the protein thought to play a role in both migraine and vestibular symptoms. These have changed how migraine is managed since 2018, and are now being tested specifically in vestibular migraine. A retrospective review found that around 6 in 10 patients showed moderate to significant improvement in their vestibular symptoms with CGRP medications.
In the UK, CGRP medications (the “-mab” injections such as erenumab, fremanezumab and galcanezumab) are funded by the NHS for chronic migraine when other preventives have failed. Access for vestibular migraine specifically depends on individual presentation and local NHS commissioning decisions. They are also available privately.
Vestibular rehabilitation and lifestyle
The main treatment for vestibular migraine is appropriate medications. Vestibular rehabilitation is only helpful in certain individuals with associated inner ear balance organ dysfunction, persistent unsteadiness or motion sensitivity between attacks. It works by helping the brain’s balance system become less reactive to everyday movement over time. The evidence is limited, but the approach is low-risk and useful for many people.
Lifestyle changes recommended for migraine generally also apply here. Consistent sleep, staying hydrated, regular meals, managing stress, and identifying and reducing personal triggers are all standard pieces of advice. Some specialists also recommend daily magnesium and vitamin B2 (riboflavin) supplements, both of which have reasonable evidence in migraine prevention and are low-risk. These measures work alongside medication rather than replacing it for those with frequent or severe attacks.
At Harley Street Audiovestibular Clinic, our audiovestibular physicians specialise in hearing and balance disorders and see vestibular migraine regularly. We take a thorough vestibular and migraine history, then carry out the testing needed to rule out the conditions that mimic it. The result is a clear diagnosis and a structured management plan, rather than another round of recurring episodes with no answers.
Frequently Asked Questions
Can you have a vestibular migraine without a headache?
Yes, and this is one of the most important points about the condition. The headache may be mild, completely absent during an attack, or arrive only after the vertigo has settled. The diagnostic criteria do not require a headache during every episode. They require a history of migraine and some migraine features (such as light or sound sensitivity, or visual disturbances) during at least half of vestibular episodes.
How is vestibular migraine different from Ménière's disease?
Both cause episodes of vertigo lasting minutes to hours. The key difference is that Ménière’s disease typically also causes fluctuating hearing loss, tinnitus and a feeling of pressure or fullness in the ear. In vestibular migraine, hearing is usually normal. Ménière’s tends to produce gradual hearing loss over time, which is not a feature of vestibular migraine. A history of migraine is a strong pointer towards vestibular migraine. The two can coexist, however, and telling them apart needs careful specialist assessment.
Is motion sickness related to vestibular migraine?
Yes. Motion sickness is significantly more common in people with vestibular migraine than in the general population. It often starts in childhood, well before vertigo episodes begin, and is now considered a useful diagnostic clue. If you have always felt sick on coaches, boats, theme park rides or in the back seat of a car, that history is worth mentioning when you see a specialist.
Will vestibular migraine go away on its own?
Some people find episodes become less frequent over time, particularly women after menopause. Without treatment, however, many people continue to have recurring attacks that disrupt work, family and daily life. Vestibular migraine is a manageable condition. With the right preventive approach and lifestyle adjustments, most people can substantially reduce how often and how severely attacks occur.
Can vestibular migraine lead to other conditions?
Yes. Vestibular migraine is one of the recognised triggers for Persistent Postural Perceptual Dizziness PPPD, where the brain’s balance system becomes persistently disrupted even between attacks. BPPV can also develop alongside or following vestibular migraine. Anyone with vestibular migraine who develops daily, constant dizziness between attacks should be assessed for both.
Can I drive if I have vestibular migraine?
You must not drive during an attack of vertigo. The DVLA’s medical guidelines require that any condition causing sudden disabling giddiness be reported, and you should pause driving if attacks are frequent, unpredictable or come with no warning. Discuss your specific situation with your GP or specialist.
When should I see a specialist for vestibular migraine?
Specialist medical assessment is vital for accurate diagnosis and management. Many other conditions can mimic or co-exist with vestibular migraine and require it to be reliably assessed. Hence make an appointment to see one of our medical experts if:
- Episodes are recurrent and disruptive
- You have been investigated and still have no clear diagnosis
- There is uncertainty about whether the cause is vestibular migraine, Ménière’s disease, BPPV or another condition
- Standard preventive treatments have not worked
Sources and further reading
- The Migraine Trust. Vestibular migraine. Available at: migrainetrust.org/understand-migraine/types-of-migraine/vestibular
- National Migraine Centre. Vestibular migraine factsheet. Available at: nationalmigrainecentre.org.uk
- NHS Lanarkshire. Vestibular Migraine Patient Leaflet.
- Mersey Care NHS Foundation Trust. Vestibular migraines guide.
- Villar-Martinez MD, Abdalla A, Goadsby PJ. (2025). Vestibular migraine: clinical and diagnostic challenges, and emerging therapeutic approaches. King’s College London. Current Opinion in Neurology.
- Lempert T, et al. (2022). Vestibular migraine: diagnostic criteria (consensus update). Bárány Society & International Headache Society.
This article is for information only and does not replace assessment by a clinician. If you are unwell now, contact your GP or NHS 111. Call 999 if you have sudden severe symptoms suggesting a stroke – facial drooping, arm weakness, or slurred speech.
