Vestibular Migraine
What is it?
Vestibular migraine is characterised by repeated spells of dizziness that may or may not be associated with a headache. It is one of the most common causes of episodic vertigo in both children and adults. As the name suggest, it is very similar to a typical migraine but instead of having headaches as the predominant feature, it is replaced by vestibular symptoms including:
- Vertigo
- Dizziness
- Nausea
- Imbalance/Unsteadiness
- Brain Fog/Heavy headiness
- Fatigue
- Sensitivity to head and environment motion, bright flicking lights, loud noises or busy environments (i.e busy shopping centres)
- Visual blurring and/or aura
- Headaches may or may not be present.
Symptoms can vary and usually can last between 5 minutes up to 72 hours.
Cause
The cause of a vestibular migraine (VM) is still not fully understood. It is widely accepted it is due to increased brain sensitivity. Migraines are often described as a disorder of sensory processing of the brain. Studies have found the brain of migraine suffers we will term “migrainous brain” are more sensitive to a “non-migrainous” brain. In the “migrainous brain” the brains ability to process information is affected. The brain is in a more excited state, meaning the brain is working at higher revs or faster speeds. This makes the brain more easily stimulated to the point of getting a migraine compared to a non-migranous brain.
An analogy we commonly use is driving at the speed limit. The “speed” in this case refers to the processing speed of the brain (i.e electrical brain circuits/pathways). Now imagine you are driving in a 60km zone and a mobile speed camera is coming up. In a non-migranous brain, the normal brain processing pathways will be going at 50-60km to ensure they do not get caught by the camera. However, in a migrainous brain, the normal brain processing pathways are constantly going at 64km, meaning another 2-5km faster and the speed camera will get them.
Normal daily activities such as driving, watching TV, reading, walking in busy environments, moving your head and responding to environment motion causes the brain processing pathways to speed up due to the increased sensory information. In the non-migranous brain, you have more of a buffer before you are caught speeding. However,in the migrainous brain, the buffer is significantly less and these activities are now too stimulating for the brain, which pushes the speed over the limit. The speed camera will then flash to catch you, signally the start of a vestibular migraine episode. Once the brain has reached this stage, it is often too late and the symptoms can last between 5 minutes to 72 hours.
A lot of vestibular migraine suffers report symptoms are significantly worse and/or get more frequent bouts of VM when they are stressed, anxious or fatigued. These factors, causes the brains processing speed to work at a higher speed which at times is enough by itself to cause VM episode. If it does not, you are now driving very close/slightly over to the speed limit and any other stimulation will likely be it over the limit and cause the VM.
Often a vestibular migraine is not well diagnosed. There are no scans that can outright diagnose a vestibular migraine. All brain scans will normally return back normal. A lot of suffers have had it for many years and just try to put up with it. However, your brain is clever and it learns quickly to avoid things that trigger the vestibular migraine. A lot of suffers report they:
- Stopped walking outside
- Do not move/turn their heads
- Stop watching TV or reading
- Unable to play sports/recreational activity
Although this may help during a vestibular migraine episode, avoiding normal activities long term will make your vestibular migraine worse. Balance and the ability of the brain to process information is a skill. If you do not USE IT you will LOSE IT. If you are start to avoid activities even after a VM episode, you are no longer challenging your balance and brain processing skill and overtime these skills will decrease quickly. The next time you try performing one of the activities, the brain will be even more sensitive to it and may bring on a VM episode, so you avoid it again. Then this vicious cycle continues and causes your symptoms to worsen over time.
Risk Factors
- Females are 9x more likely to develop it. This is believed to be due to the hormonal differences between the two genders. A lot of VM report symptoms can worsen during menstruation/menopause.
- Often have a prior history of migraines or motion sickness when they were younger which develops into a VM
Triggers
- Stress and Anxiety
- Certain foods/drinks (not all people have food triggers)
- Sodium, dairy, caffeine, alcohol, carbohydrates, gluten
- Poor Sleep
- Overworking and Fatigue
- Hormonal changes (during menstruation or menopause)
- Hunger (skipping meals) or dehydration
- Smoking
- Environment Factors
- Strong smell
- Loud Noises
- Bright Flicking Lights
- Busy Environments (shopping centres)
- Looking out the window in a car, train, bus
Treatment
Once a VM is diagnosed, management includes decreased avoidable triggers (i.e reducing stress, improving sleep, not skipping meals). The vestibular physiotherapist will have a thorough initial assessment and also prescribed an individualised exercise program that may include vestibular rehabilitation. These include:
- Static and Dynamic Balance
- Vestibular-Ocular Reflex Exercises
- Oculomotor Exercises
- Habituation Exercises for head/environment movement
- Refer to other professions (i.e neurologist, psychologist) if required
Once rehabilitation commences, VM suffers will get better. This may take a few weeks or months but varies depending on your symptoms, how long you have had it and any other comorbidities.
At times, it may be recommended medications (i.e anti-depressants, SSRI) may be required to assist with rehabilitation if you are not tolerating the exercises and/or are slow to progress. There is often a negative connotation with anti-depressants as patients feel it is for depression, however as the name suggest it can greatly assist in slowing down the brain activity (speed limit analogy) so you are able to tolerate the exercises and speed up recovery with aims to hopefully wean off these medications when appropriate. Similar asthma suffers where some have Ventolin puffers and some do not need it, some VM suffers may not require medications and some do.
If you have had any of these symptoms mentioned above or you tick quite a few boxes whilst reading this, we recommend you book in with a vestibular physiotherapist to get down to the root cause of your conditions and return you to moving well!
John Ma
Vestibular Physiotherapist