Vestibular migraine is a seemingly spontaneous episode of vertigo, sometimes accompanied with headache, that impairs your ability to function. Dizziness can be part of aura before a migraine headache, but in vestibular migraine, vertigo is the main symptom, with or without headache. Dizzy migraines are incapacitating and difficult to explain the impact that your symptoms have on your ability to work, drive, exercise and socialise to family and colleagues. Vestibular migraine treatment with vestibular rehabilitation decrease the intensity and frequency of your attacks. If you experience loss of balance with headache, you may be suffering from vestibular migraine.

Your vestibular apparatus is your body’s gyroscope. You have one on each side that mirrors the function of the opposite partner. The vestibulocochlear nerve, CN VIII, communicates with your brain to enable balanced, smooth, coordinated movement by interpreting head and body position in space and changes in velocity. This all happens within milliseconds and is controlled via reflexes, the vestibular ocular, vestibulo spinal and vestibulo collic reflexes .

Your vestibular apparatus is snugly embedded in your temporal bones. Your temporal bones are part of your skull, in your hairline above and around your ear. You may have heard the phrase “temporal headache” to describe pain in this area. Deeper within the bone, tucked into its special compartment or vestibule, sits your vestibular apparatus.

The hard bony labyrinth protects the soft membranous labyrinth, in the same way as the skull protects the brain. The bony labyrinth is filled with perilymphatic fluid that has a similar composition to cerebrospinal fluid. In contrast, the membranous labyrinth is filled with endolymph, with a similar composition to intracellular fluid. These different recipes of fluid result in different viscosities, which is important for the functioning of your gyroscopes.

You have five organs that sense movement and body position on each side, three semicircular canals (SCC) and two otoliths.

Input from the vestibular apparatus

Balance is dependent on your eyes, body and ears, like a tripod. How the brain interprets the sensory information it receives from sight, proprioception and the vestibular apparatus determines if you read signposts from a moving car without feeling sick.

Your semicircular canals detect changes in velocity. These three canals are at right angles to one another and communicate with the opposing SCC of the opposite side. That means your right posterior SCC communicates with your left anterior SCC. They can be described as the x,y and z axes of a 3D graph.

The otoliths detect changes in linear acceleration and gravity. Your utricle relays the change of linear speed, like the movement in a car. While your saccule detects gravitational change in an elevator.

Nerve impulses are generated when hair cells, stereocilia, at the base of the semicircular canal or otolith, the ampulla, are deflected because of the movement of endolymph, almost like seaweed in a current. This movement of the endolymph bends or deflects the stereocilia. This movement causes mechano-sensitive ion channels to open in the hair cell membrane. Potassium, from the potassium-rich endolymph, flows through these channels and changes the electrical potential. When the membrane’s electric potential changes, the firing rate of the nerve cells also changes.

Output from the brain to the eyes

These messages are sent straight to your brain stem, medulla oblongata. An almost immediate response is sent to adapt so that you can keep your focus and steady gaze. When reading this article and shaking your hear “yes” up and down, or “no” left and right, you should be able to keep reading, because your brain tells your eye muscles to move at exactly the same speed in the opposite direction, also working as a pair. If that doesn’t happen you will lose focus, the words get blurry and you’ll feel dizzy.

That’s why having an eye test and determining how good your sight is, means very little to how the brain interprets gaze and movement.

• If you have a family member suffering from dizzy migraines, your risk is higher to develop vestibular migraine.

• Hormonal fluctuations during menstruation and menopause
• Stress, both emotional and physical, influences cortisol, which in turn influences your entire system
• Sleep deprivation
• Diet
• Environment, like changes in barometric pressure, bright lights, loud noise and strong odours
• Head movements during leisure and exercise, like burpees or sun salutations
• Visual tracking, like counting livestock or watching sport
• Sensory conflict, like stationary cycling or treadmill running
• Dehydration
• Blood sugar

3. Systemic/local comorbidities

• Temporary changes in perfusion from blood vessels can alter nerve activity and trigger vestibular migraine
• Existing anxiety, depression and benign paroxysmal vertigo of childhood increase your risk of vestibular migraine

You do not have to suffer from headache pain to be diagnosed with vestibular migraine. Answer the following questions to see if you have vestibular migraine:

Any vestibular pathology is difficult to explain to family or colleagues because it’s not like an ankle sprain, where you can see the injury. You can look  100% fine, but feel awful, unsteady, unproductive, frustrated and worried in equal measure.

A stay-at-home mum’s functionality will be just as affected as a corporate worker, though she won’t be able to get sick leave. Vestibular migraine attacks can vary in intensity and duration. More intense attacks that last for 2 days are worse than a single attack a year. If you are very sensitive to visual or motion stimuli, you can get an attack from reading the arrival list at the airport.

When your attacks are affecting your relationships, work, sport pursuits and mood, you are affected more than the guy who gets one attack 6 hours after riding all the rollercoasters at gold reef city.

Vestibular migraine is a clinical diagnosis of exclusion, meaning no other structural pathology should be causing your attacks. Physiotherapists with experience in treating headaches/migraine will take a thorough history to exclude other causes of your symptoms. Your symptom severity will guide your physio to not only check your neck joints, ligaments and muscles, but also your visual tracking, motion sensitivity, and dynamic visual acuity. We understand how sensory integration is the base of your balance.

Audiogram testing and electronystagmography (ENG) is done by audiologists to determine if you have hearing loss or other pathology of your vestibular apparatus.

Your physiotherapist can refer you to an audiologist.

Vision screening can be done by an optometrist. This excludes any vision problems as the cause of your symptoms.

If you need a vision test, your physio will refer you to an optometrist.

An MRI scan can be used to rule out any other pathology, like a space-occupying vestibular schwannoma. This image can only be ordered by your specialist and is not needed to confirm vestibular migraine.

Your brain is sensitive to sensory mismatch. When the messages from your body’s proprioception, eyes and ears are different, the result is dizziness. This is a fantastic strategy to keep you safe, because when dizzy and nauseous, you won’t engage in travel and sport where the risk for injury is greater.

Although your brain has the amazing capacity for healing and creating new pathways with neural plasticity, it won’t “waste time”. It will force the quickest compensation that keeps you safe. With rehabilitation, we can ensure compensation and habituation that is functional and lasts.

You cannot “rest” it away; the less you do, the smaller your capacity shrinks. Avoiding triggers forever won’t make it go away. On the contrary, it will only make your threshold smaller needed to cause an attack.

• Complications

Chronic vertigo symptoms increase your risk of developing persistent postural perceptual dizziness (PPPD). PPPD/3PD is a chronic condition causing constant dizziness of varying intensity, usually first triggered by an intense attack, like a dizzy migraine. It is worsened by movement, such as being in a car, and perceiving your surroundings as moving when they are not.

• Misdiagnosis

Many people are diagnosed with BPPV as the cause of their dizziness, when it is not.

• Misconceptions about treatment

When patients are wrongly diagnosed with BPPV, they expect a quick fix with a repositioning manoeuvre. Rehabilitation takes time and effort. No recovery is linear; there will be bad days, and you may feel frustrated and afraid. Nothing worthwhile is easy; be patient and put in the work.

Our priority is to determine your vestibular integration and sensory capacity. Physiotherapy for vestibular migraine treatment aims to facilitate the correct compensation of your vestibular apparatus to ensure balance and safety when you move and change position. We do this by slowly adapting your rehabilitation program to increase your capacity to correctly interpret sensory information from moving visual targets to you balancing and moving along.

We understand the functional limitations you are experiencing because of your dizzy migraine. Our physiotherapists offer a structured plan of action to guide your rehabilitation and progression to increase your balance. The more stable you feel, the more you can participate in position changes, visual pursuits and travel.

Vestibular migraines are not cured, but managed. The recovery from an attack can take up to 72 hours. Understanding what contributes to your dizzy migraines is the first step in managing your symptoms. When you should take what medication and taking care of the basics like sleep, hydration and blood sugar is important to avoid vestibular migraine attacks. Having a hat and sunglasses, sitting at the head of the table instead of looking from side to side during a conversation, is part of your lifestyle modifications.

Our aim with vestibular rehabilitation is to lessen the frequency of your vestibular migraine attacks.

• Your doctor (GP/ENT/neurologist) can prescribe medication, like NSAIDs and triptans for decreasing the intensity of an attack or beta-blockers, calcium channel blockers, antidepressants and anti-epileptic medication to reduce the frequency of the attacks.
• Be sure that you understand how and when to use what medication to have the desired effect on your dizzy migraines.
• Getting prescription lenses from your optometrist can reduce visual triggers of your vestibular migraine.

Surgery is not the first line of treatment for vestibular migraine. Surgical options are destructive procedures with complete hearing loss of the operated ear. Your ENT surgeon will discuss which surgical options you have, and may include:

• Transient ischemic attack (TIA)

Extreme headache, dizziness, weakness and speech difficulty can be symptoms of an ischemic attack where your brain isn’t getting enough oxygen. This is a medical emergency and needs immediate medical attention.

• BPPV

When otoconia move within your semicircular canals, you will feel extreme dizziness of short duration directly linked to head movements.

• Vestibular Neuritis

An acute infection of your vestibulocochlear nerve can cause ear ache hearing loss, vertigo, aural fullness, tinnitus.

• Meniere’s Disease

Hearing loss, vertigo, aural fullness and tinnitus without a history of trauma may be caused by Meniere’s Disea

• Migraine-associated vertigo
• Dizzy migraine
• Migraine-related vestibulopathy
• Loss of balance with a headache
• Migrainous vertigo