Vestibular Migraine Diagnosis and Examination

Key Examination Components

• The American Academy of Otolaryngology-Head and Neck Surgery recommends a physical examination to identify central versus peripheral vestibular pathology and rule out other vestibular disorders through specific provocative maneuvers and neurologic assessment 1, 2
• A cranial nerve examination is necessary to identify abnormalities suggesting brainstem or cerebellar pathology, such as dysarthria, dysphagia, dysmetria, sensory/motor deficits, and Horner's syndrome 2, 3
• Visual disturbance assessment is crucial to identify symptoms beyond typical migraine aura 4, 3
• Severe headache evaluation is necessary to indicate potential intracranial pathology 4, 3

Nystagmus Evaluation

• The American Academy of Otolaryngology-Head and Neck Surgery suggests that downbeating nystagmus on Dix-Hallpike maneuver, particularly without torsional component, indicates central pathology rather than vestibular migraine 2
• Direction-changing nystagmus without changes in head position (periodic alternating nystagmus) suggests central pathology 2
• Gaze-evoked nystagmus (beats to the right with right gaze, to the left with left gaze) indicates central pathology 2
• Baseline nystagmus without provocative maneuvers suggests central pathology 2

Balance Testing and Fall Risk

• Assessment for fall risk is necessary, particularly in patients with impaired mobility, CNS disorders, or lack of home support 2

Dix-Hallpike Maneuver

• A positive Dix-Hallpike with classic BPPV pattern (upbeating-torsional nystagmus with latency and fatigue) suggests BPPV rather than vestibular migraine 2, 5
• Vestibular migraine may show atypical positional responses but should not demonstrate classic BPPV nystagmus 1, 2

Additional Testing

• The Barany Society criteria (≥5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, migraine history, migrainous features during ≥50% of episodes) can be used to determine when additional testing is not needed 1, 6
• Routine vestibular function testing and neuroimaging should not be obtained when the clinical diagnosis of vestibular migraine is clear based on Barany Society criteria 1, 6
• Additional neurologic symptoms, such as abnormal cranial nerves, visual disturbances, and severe headache, suggest central pathology and require additional testing 4, 3
• Atypical nystagmus patterns or those suggesting central pathology require additional testing 2, 5, 6
• Unclear or uncertain clinical presentation requires additional testing 5, 6
• Multiple concurrent vestibular disorders require additional testing 5, 6
• Patient failure to respond to appropriate treatment requires additional testing 2

Common Pitfalls

• Missing central pathology can occur if brainstem/cerebellar signs are not assessed, as 10% of cerebellar strokes can present similarly to peripheral vestibular processes 2
• Over-testing clear diagnoses can delay treatment when Barany criteria are met 1, 6