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Vestibular Migraine Revisited: A Narrative Review of Diagnostic Challenges and Treatment Strategies

Vlastarakos P, Sideris G, Kourklidou M, Bousi V, Michailidou E, Nikolopoulos T

The journal of international advanced otology, 2025

Abstract

Vestibular migraine (VM) is a common yet frequently underdiagnosed neurological condition, marked by recurrent episodes of vertigo and other vestibular symptoms in association with migraine features. It predominantly affects women aged 30-50 years and has an estimated prevalence of 1%-5% in the general population. This narrative review explores current knowledge surrounding VM, including its epidemiology, proposed mechanisms, diagnostic complexities, and treatment approaches. The pathophysiology remains incompletely understood but may involve dysfunction in vestibule-cerebellar pathways, ion channel abnormalities, and trigeminal system activation. Diagnosing VM is clinically driven, requiring careful evaluation of vestibular complaints alongside migraine-associated symptoms. Patients commonly report vertigo and headaches, while clinical assessment may uncover ocular motor disturbances, canal paresis, and balance issues. Supplementary tests such as ocular and cervical vestibular evoked myogenic potentials can aid in diagnosis, though they are not definitive. Differential diagnosis is essential due to symptom overlap with other vestibular disorders like Ménière's disease, episodic ataxia type 2, and benign paroxysmal positional vertigo. Treatment includes acute interventions with vestibular suppressants and triptans, vestibular rehabilitation programs, and preventive pharmacotherapy such as β-blockers, calcium channel blockers, and certain antidepressants. Despite these…

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