Previously used terms:

Migraine-associated vertigo/dizziness; migraine-related vestibulopathy; migrainous vertigo.

Diagnostic criteria:
  1. At least five episodes fulfilling criteria C and D
  2. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura1
  3. Vestibular symptoms2 of moderate or severe intensity3, lasting between 5 minutes and 72 hours4
  4. At least half of episodes are associated with at least one of the following three migrainous features5:
      1. headache with at least two of the following four characteristics:
        • a) unilateral location
        • b) pulsating quality
        • c) moderate or severe intensity
        • d) aggravation by routine physical activity
      2. photophobia and phonophobia6
      3. visual aura7
  5. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder8.
Notes:
  1. Code also for the underlying migraine diagnosis.
  2. Vestibular symptoms, as defined by the Bárány Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of A1.6.6 Vestibular migraine, include:
    • a) spontaneous vertigo:
      • – internal vertigo (a false sensation of self-motion);
      • – external vertigo (a false sensation that the visual surround is spinning or flowing);
    • b) positional vertigo, occurring after a change of head position;
    • c) visually-induced vertigo, triggered by a complex or large moving visual stimulus;
    • d) head motion-induced vertigo, occurring during head motion;
    • e) head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).
  3. Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued.
  4. Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.
  5. One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.
  6. History and physical examinations do not suggest another vestibular disorder or such a disorder has been considered but ruled out by appropriate investigations or such a disorder is present as a comorbid condition but episodes can be clearly differentiated. Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks.
Comments:

A surprisingly high prevalence of A1.6.6 Vestibular migraine of 10.3% was recently described among migraine patients in Chinese neurological departments.

Other symptoms

Transient auditory symptoms, nausea, vomiting, prostration and susceptibility to motion sickness may be associated with A1.6.6 Vestibular migraine. However, since they also occur with various other vestibular disorders, they are not included as diagnostic criteria.

Relation to migraine aura and migraine with brainstem aura

Both migraine aura and migraine with brainstem aura (formerly: basilar-type migraine) are terms defined by ICHD-3. Only a minority of patients with A1.6.6 Vestibular migraine experience their vertigo in the time frame of 5-60 minutes as defined for an aura symptom. Even fewer have their vertigo immediately before headache starts, as required for 1.2.1.1 Typical aura with headache. Therefore, episodes of A1.6.6 Vestibular migraine cannot be regarded as migraine auras.