What is vestibular migraine — and why does it cause dizziness and vertigo?

Vestibular migraine is a type of migraine that causes episodes of dizziness, vertigo (a spinning sensation), or problems with balance — often with little or no head pain. It's now recognized as the most common cause of spontaneous episodic vertigo in adults.¹ Despite how common it is, vestibular migraine is frequently missed. Many people spend years chasing a diagnosis, bouncing between ENT doctors and neurologists, before anyone connects the dizziness to migraine.

It can be diagnosed. And it can be treated.

Key takeaways

• Vestibular migraine causes recurring episodes of vertigo or dizziness lasting 5 minutes to 72 hours, tied to a history of migraine.¹
• Head pain may be mild or absent — many people never realize their dizziness is migraine-related.²
• It affects roughly 2.7% of the general population and is frequently under-diagnosed.¹
• Diagnosis follows joint clinical criteria from the Bárány Society and the IHS, updated in 2022.⁵
• Treatment has three pillars: acute medicines, daily preventive medicines, and vestibular rehabilitation therapy.⁸

What does vestibular migraine feel like?

An attack can arrive with or without head pain. Many people — and many clinicians — don't connect the dots at first.

During an attack you might experience:

• Vertigo (a spinning or tilting sensation, even when you're still)
• Dizziness or a sense of being off-balance
• Unsteadiness when you walk or move your head
• Feeling nauseated by motion or visual stimulation
• Sensitivity to light, phonophobia (noise sensitivity), or both
• Difficulty focusing or a sense that the world is moving

Episodes vary widely in length. About one-third of people have attacks that last only minutes. Another third have attacks that stretch for hours, and roughly a third experience symptoms over several days.³

Between attacks, most people feel fine — though some notice persistent balance trouble or sensitivity to movement.⁴

One thing that surprises a lot of people: head pain shows up in fewer than half of all vestibular migraine attacks — about 50% of the time.⁴⁶ If your vertigo comes without a headache, vestibular migraine can still be the cause.

What causes vestibular migraine?

The exact cause isn't fully understood.⁶ What researchers do know is that the brain's migraine network interacts directly with the vestibular system — the network in your inner ear and brainstem that controls balance and spatial orientation.

A protein called CGRP (calcitonin gene-related peptide) triggers inflammation in migraine pathways. It's also found in the inner ear's vestibular pathways, which likely explains why migraine can produce dizziness and vertigo.² Imaging studies show people with vestibular migraine have abnormal activity in several brain regions — a pattern distinct from typical migraine.⁷ The brain is processing sensory signals differently, and that difference throws off your sense of balance.

Common triggers that can set off an attack include:

• Menstruation
• Stress
• Poor sleep or irregular sleep
• Dehydration
• Certain foods (caffeine, alcohol, aged cheeses, MSG)
• Bright or flickering lights
• Busy visual environments

These triggers overlap with general migraine triggers, which is another clue that vestibular migraine is a true migraine variant, not a separate condition.

How is vestibular migraine diagnosed?

No blood test or brain scan confirms vestibular migraine. Diagnosis is clinical — it rests on your history and your symptoms.

The Bárány Society and the International Headache Society (IHS) jointly published formal diagnostic criteria, last updated in 2022.⁵ To meet those criteria, a person must have:

1. At least 5 episodes of moderate-to-severe vestibular symptoms (vertigo, dizziness, or balance problems)
2. A current or past history of migraine with or without aura
3. At least one migraine-associated feature during at least 50% of attacks — such as head pain, light sensitivity, noise sensitivity, or visual aura
4. Symptoms lasting between 5 minutes and 72 hours
5. No better explanation from another vestibular or neurological condition

No single feature clinches the diagnosis. That's why getting it right usually means seeing someone who knows both headache disorders and vestibular medicine well. Many people wait years to reach that person.

How vestibular migraine differs from BPPV and Ménière's disease

Two conditions that are commonly confused with vestibular migraine are BPPV (benign paroxysmal positional vertigo) and Ménière's disease.

A headache specialist can help sort out which condition — or combination — is at play. Some people have more than one vestibular disorder at once, which is another reason an expert evaluation matters.¹⁵

Who gets vestibular migraine?

Vestibular migraine affects roughly 2.7% of the general population.¹² Like migraine overall, it's more common in women than in men. It can start at any age — including in children, where it often appears as recurring episodes of vertigo without any head pain.³

Despite how many people are affected, it's still regularly missed. Clinicians may focus on the dizziness and refer to an ENT, missing the migraine connection entirely. Some patients get told their symptoms are anxiety or that nothing is wrong. They aren't, and something is.

Vestibular migraine is a real neurological condition with established diagnostic criteria and real treatment options.⁶

How is vestibular migraine treated?

Treatment follows the same general framework as migraine: acute medicines to stop an attack, preventive medicines to reduce how often attacks happen, and non-medication strategies that support both.⁶⁸

[Infographic 2: Vestibular migraine treatment — three pillars. Upload vm_fig2_treatment.png here.]

Acute (rescue) treatment

For stopping an attack in progress, clinicians may recommend:

• Triptans — the main acute medicines used in migraine care
• Anti-nausea medicines (ondansetron, metoclopramide, promethazine) to ease nausea and dizziness
• Antihistamines or vestibular suppressants (such as meclizine) for short-term relief

These medicines are taken at the start of an attack. Talk with your clinician before starting any of them.

Preventive (daily) treatment

When attacks are frequent or severe enough to affect daily life, preventive medicine can reduce how often they happen. A 2025 systematic review of nine studies (687 patients total) found consistent support for several options:⁸

• Beta-blockers (such as propranolol) — consistently reduced vestibular migraine symptoms in studies using validated dizziness scales
• Antiepileptics (such as topiramate) — reduced symptom frequency in multiple trials
• CGRP monoclonal antibodies (such as erenumab and galcanezumab) — showed favorable efficacy and tolerability⁸⁹
• Antidepressants — outcomes are more variable, but some people benefit

No single preventive works for everyone. Your clinician will weigh the options based on your attack pattern, other health conditions, and what you've already tried.

Vestibular rehabilitation

Vestibular rehabilitation therapy (VRT) is a specialized form of physical therapy that improves balance, reduces motion sensitivity, and helps the brain adapt to vestibular changes. Used alongside preventive medicine, it can make a meaningful additional difference — especially for people with lingering balance problems between attacks.⁸ It works best when introduced gradually. Overly intense vestibular exercises can trigger an attack, so the pace matters.

Lifestyle modifications

Many of the same lifestyle adjustments that help with migraine also help with vestibular migraine:⁶

• Regular exercise
• Consistent sleep schedule
• Eating regular meals and staying hydrated
• Stress reduction
• Avoiding known dietary triggers (caffeine, alcohol, MSG, highly processed foods)

These are low-risk and genuinely useful — especially layered alongside medicine or rehabilitation.

When should you see a specialist?

See a headache specialist if:

• You have recurring episodes of dizziness or vertigo with no clear explanation
• You have a history of migraine and are now experiencing balance problems
• Your vestibular symptoms are interfering with work, driving, or daily life
• You've seen other specialists but still don't have a diagnosis

A headache specialist with experience in vestibular disorders can evaluate both the migraine and the balance component together — and build a plan that addresses both.

If you ever experience a sudden, severe headache — the worst of your life — or dizziness with new weakness, vision loss, or trouble speaking, seek emergency care right away. These can be signs of something requiring urgent attention.

You deserve answers — and a real plan

Living with unexplained dizziness is exhausting. Years of referrals, normal test results, and still no clear answer. That's the reality for a lot of people with vestibular migraine — and it doesn't have to stay that way.

Getting the right diagnosis changes what's possible. Once you know what you're dealing with, you can actually start treating it. For most people, that makes a real difference.

If you think vestibular migraine might be part of what you're going through, Haven Headache & Migraine Center can help. Our clinicians specialize in headache and migraine care, including vestibular migraine. We offer virtual and in-person appointments, so care fits your life — not the other way around.

Medically reviewed by: Karissa Secora, DMSc, PA-C, AQH, Haven Headache & Migraine Center
Peer reviewed by: Karly Kozlowski PA-C, BHS, MPA, Haven Headache & Migraine Center

References

1. Eggers SDZ, Staab JP. Vestibular migraine and persistent postural perceptual dizziness. Handbook of Clinical Neurology. 2024;199:389–411. https://pubmed.ncbi.nlm.nih.gov/38307659/
2. Benjamin T, Gillard D, Abouzari M, Djalilian HR, Sharon JD. Vestibular and auditory manifestations of migraine. Current Opinion in Neurology. 2022;35(1):84–89. https://pubmed.ncbi.nlm.nih.gov/34864754/
3. International Headache Society (ICHD-3). A1.6.6 Vestibular migraine. https://ichd-3.org/appendix/a1-migraine/a1-6-episodic-syndromes-that-may-be-associated-with-migraine/a1-6-6-vestibular-migraine/
4. Beh SC. Vestibular migraine. Current Neurology and Neuroscience Reports. 2022;22(10):601–609. https://pubmed.ncbi.nlm.nih.gov/36044103/
5. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: Diagnostic criteria (Update). Journal of Vestibular Research. 2022;32(1):1–6. https://journals.sagepub.com/doi/full/10.3233/VES-201644
6. Cantillo-Martínez M, Lorente-Piera J, Manrique-Huarte R, et al. Insights into vestibular migraine: Diagnostic challenges, differential spectrum and therapeutic horizons. Journal of Clinical Medicine. 2025;14(14):4828. https://pmc.ncbi.nlm.nih.gov/articles/PMC12294935/
7. Ceriani CEJ. Vestibular migraine pathophysiology and treatment: a narrative review. Current Pain and Headache Reports. 2024;28(2):47–54. https://pubmed.ncbi.nlm.nih.gov/37889468/
8. Almohammed HA, Thalib HI, Kushara KF, et al. Prophylactic management of vestibular migraine: a systematic review. Annals of Clinical and Translational Neurology. 2025;12(12):2384–2397. https://pmc.ncbi.nlm.nih.gov/articles/PMC12698959/
9. Vasireddy S, Biswas S, Kollu R, et al. Comparative effectiveness and safety of preventive treatments for vestibular migraine: a systematic review and network meta-analysis. BMC Neurology. 2025;25(1):513. https://pmc.ncbi.nlm.nih.gov/articles/PMC12754936/

Frequently asked questions

What is vestibular migraine?

Vestibular migraine is a type of migraine that causes recurring episodes of vertigo, dizziness, or balance problems. Unlike typical migraine, head pain is often mild or absent. It is the most common cause of spontaneous episodic vertigo in adults.¹

Can you have vestibular migraine without a headache?

Yes. Head pain accompanies vestibular migraine attacks only about half the time.⁴ ⁶ Many people with vestibular migraine are never told migraine is the cause of their dizziness precisely because there's no headache to flag it.

How is vestibular migraine different from BPPV?

BPPV (benign paroxysmal positional vertigo) causes brief spinning episodes lasting only seconds, triggered by specific head movements. Vestibular migraine attacks last much longer — 5 minutes to 72 hours — and are tied to a history of migraine, not to head position changes.⁵ A clinician can help distinguish between them.

What triggers vestibular migraine attacks?

Common triggers include stress, poor sleep, hormonal changes (especially menstruation), dehydration, certain foods and drinks (caffeine, alcohol, MSG), and visually busy environments.⁵ ⁶ Triggers vary from person to person, which is why keeping a headache diary is worth the effort.

What medicines are used to treat vestibular migraine?

For acute attacks, triptans, anti-nausea medicines, and vestibular suppressants can help. For prevention, beta-blockers (such as propranolol), antiepileptics (such as topiramate), and CGRP monoclonal antibodies have shown benefit in clinical studies.⁸ ⁹ Vestibular rehabilitation therapy can also reduce dizziness and improve balance over time.⁸

Does vestibular migraine go away on its own?

Vestibular migraine is a chronic neurological condition — attacks don't typically stop without treatment. With the right combination of medicines, lifestyle changes, and rehabilitation, many people see meaningful reductions in attack frequency and severity.⁸ ⁹

Is vestibular migraine serious?

It's not life-threatening, but it can severely affect quality of life. Attacks can make it difficult to drive, work, or carry out daily activities.⁴ Getting an accurate diagnosis and starting treatment matters — the condition shouldn't go unmanaged.

Can children have vestibular migraine?

Yes. In children, vestibular migraine often presents as recurring episodes of vertigo without head pain — a pattern recognized by both the Bárány Society and the International Headache Society.³ These episodes often precede or coexist with typical migraine later in childhood or adulthood.

This article is for general education and is not medical advice. It is not a substitute for care from a qualified health professional. Always talk with your clinician before starting, stopping, or changing any treatment. If you have a sudden, severe headache, the worst headache of your life, or a headache with new symptoms like weakness, trouble speaking, or vision loss, seek emergency care right away.

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