Vestibular Migraine and Chronic Migraine with Vestibular Features: Diagnostic Guidelines

Diagnostic Criteria and Core Features

• Chronic migraine is defined by headaches on ≥ 15 days per month for ≥ 3 months, with ≥ 8 days meeting migraine criteria – criteria endorsed by the Mayo Clinic Guidelines 3, 4.
• Daily headaches persisting for years satisfy chronic migraine criteria – supported by the American Academy of Otolaryngology–Head and Neck Surgery (AAO‑HNS) 1, 2.
• Episodic dizziness that appears suddenly (“out of nowhere”) reflects a spontaneous episodic vestibular syndrome, a hallmark of vestibular migraine – AAO‑HNS 5, 6.
• Brief visual blackouts lasting only seconds, without loss of consciousness, may represent visual aura or an orthostatic migraine component – AAO‑HNS 1, 7.
• Improvement of symptoms when the head is supported suggests cervical muscle tension and postural triggers commonly seen in vestibular migraine – AAO‑HNS 6.

Secondary and Overlapping Conditions

• Cervicogenic contribution is signaled by symptom relief with head support and is considered a red‑flag clue – AAO‑HNS 6, 8.
• Cervicogenic headache is provoked by cervical movement, accompanied by reduced cervical range of motion and myofascial tenderness – Journal of Neurology, Neurosurgery & Psychiatry 8.
• Cervicogenic mechanisms can coexist with migraine rather than being mutually exclusive – AAO‑HNS 6.
• Vertebrobasilar insufficiency may present initially as isolated transient vertigo and can precede stroke by weeks to months – AAO‑HNS 10, 2.
• Brief visual blackouts with tinnitus may indicate posterior‑circulation transient ischemic attacks – AAO‑HNS 5, 6.
• Vascular risk factors such as older age, hypertension, and atrial fibrillation raise suspicion for vertebrobasilar insufficiency – Journal of the American College of Radiology 12.
• Ménière’s disease typically shows sustained vertigo attacks, fluctuating hearing loss, aural fullness, and tinnitus; its absence of documented hearing loss and the brief visual symptoms make it less likely in this context – AAO‑HNS 5, 9, 1.
• Spontaneous intracranial hypotension characteristically causes “end‑of‑day” headaches that improve when lying flat; the chronic, years‑long course makes this diagnosis unlikely without evidence of a chronic CSF leak – Journal of Neurology, Neurosurgery & Psychiatry 8.
• Postural orthostatic tachycardia syndrome (PoTS) should be considered when dizziness has a postural component and improves with head support; diagnosis requires a standing test showing a heart‑rate increase > 30 bpm – Journal of Neurology, Neurosurgery & Psychiatry 8.

Red‑Flag Features Requiring Urgent Evaluation

• Brief visual blackouts may represent posterior‑circulation ischemia and warrant immediate neuroimaging – AAO‑HNS 10, 2.
• A new or changing pattern of dizziness (“more recently comes out of nowhere”) suggests evolving pathology and should prompt urgent assessment – AAO‑HNS 5.
• Long‑standing daily headaches with newly emerging vestibular symptoms necessitate exclusion of posterior‑fossa mass lesions – AAO‑HNS 5, 6.

Recommended Diagnostic Work‑up

• Headache diary to document frequency and confirm chronic migraine (≥ 15 days/month) – Mayo Clinic Guidelines 4.
• Systematic assessment of migraine features (unilateral location, pulsating quality, moderate‑severe intensity, photophobia, phonophobia, nausea) – AAO‑HNS 1, 7.
• Formal standing test to evaluate for PoTS or orthostatic hypotension – Journal of Neurology, Neurosurgery & Psychiatry 8.
• Cervical examination for range of motion and myofascial tenderness – Journal of Neurology, Neurosurgery & Psychiatry 8.
• MRI of the brain without intravenous contrast to exclude posterior‑circulation infarct, posterior‑fossa mass, and other structural causes – Journal of the American College of Radiology 12.
• Diagnostic yield of MRI in isolated dizziness is low (~4 %), but increases with vascular risk factors and combined symptomatology – Journal of the American College of Radiology 12.
• Magnetic resonance angiography (MRA) of head and neck should be considered when vertebrobasilar insufficiency is a concern – Journal of the American College of Radiology 12.
• Formal audiometry to identify any hearing loss that would support Ménière’s disease – AAO‑HNS 5, 9.

Common Pitfalls to Avoid

• Do not dismiss daily headaches as tension‑type without applying chronic migraine criteria – Mayo Clinic Guidelines 3, 4.
• Do not assume brief visual symptoms are benign without ruling out posterior‑circulation ischemia, especially in the presence of vascular risk factors – AAO‑HNS 10, 2.
• Do not overlook a cervicogenic component; symptom relief with head support is a specific clue – AAO‑HNS 6, 8.