Vestibular migraine — recurring vertigo and its migraine connection

A spinning world — what vestibular migraine actually is

Vestibular migraine is the commonest cause of recurring spontaneous vertigo in adults. It affects roughly 1% of the Australian population — approximately five times more common than Menière’s disease — and is markedly under-recognised in general practice, where it is often mislabelled as “chronic dizziness” or benign paroxysmal positional vertigo.

The key insight is that vestibular migraine is not primarily a dizziness disorder. It is a migraine variant — part of the same biological system as classic migraine headaches — in which the migraine process expresses itself through the balance and vestibular pathways in the brainstem rather than (or as well as) through the headache pathway. The treatments are drawn from the same family as migraine treatments.

Episodes typically last between five minutes and 72 hours. They may involve spontaneous spinning vertigo (the room feels like it is rotating), dizziness provoked by head movement or visual motion (busy shopping aisles, traffic, scrolling screens), positional vertigo, or a sense of unsteadiness and imbalance. Critically, around 30% of attacks occur with no headache at all — particularly as the condition progresses. This is one reason the condition is so frequently missed.

Migraine & Headache Australia reports that vestibular migraine predominantly affects women (female to male ratio approximately 3:1), with peak presentation between ages 30 and 50. A family history of migraine is present in roughly 60% of cases. Many patients have experienced episodic migraine headaches earlier in life, sometimes in adolescence, which gradually evolved or alternated with vestibular episodes over time.

A. Core clinical — the AU general-practice framework

How vestibular migraine is diagnosed

Vestibular migraine is a clinical diagnosis — there is no blood test or scan that confirms it. The Bárány Society / International Classification of Vestibular Disorders criteria, incorporated into the International Classification of Headache Disorders (ICHD-3 A1.6.6), require all of the following:

1. Five or more attacks of moderate-to-severe vestibular symptoms.
2. Duration 5 minutes to 72 hours per episode.
3. A current or past history of migraine with or without aura.
4. Migrainous features in at least 50% of attacks — at least one of: one-sided pulsating headache aggravated by activity; photophobia plus phonophobia; or visual aura.
5. No better explanation from another vestibular or headache diagnosis.

Vestibular symptoms counted by the criteria include spontaneous vertigo (internal or external), positional vertigo, visually-induced vertigo, head-motion-induced vertigo with nausea, and head-motion-induced dizziness with nausea.

Your GP will take a detailed history: how each episode begins, how long it lasts, what it feels like, whether headache or light and sound sensitivity accompanies the dizziness, what triggers you have noticed, your full headache history (including childhood motion sickness and any past episodes labelled “episodes of dizziness”), and whether you experience tinnitus, hearing change, or a sense of ear fullness — which would raise the possibility of Menière’s disease.

Physical examination between episodes is usually normal in vestibular migraine. Your GP will assess eye movements looking for nystagmus, perform a head-impulse test, and may carry out the Dix-Hallpike manoeuvre to exclude BPPV. Blood pressure both lying and standing rules out orthostatic causes. Cranial nerve, cerebellar, and gait assessment round out the neurological examination. Importantly, finding a normal neurological examination does not mean the symptoms are not real — vestibular migraine is neurological by nature, but the abnormalities occur during attacks, not between them.

Investigations

eTG and RACGP guidance on vertigo in general practice are clear that investigations are used to exclude alternative diagnoses, not to confirm vestibular migraine.

Audiogram: Any hearing complaint, tinnitus, or aural fullness warrants a formal hearing test. Vestibular migraine typically produces a normal audiogram; Menière’s disease causes characteristic low-frequency sensory hearing loss — an important distinction.

MRI brain: Indicated for atypical presentations, first episode over age 50, asymmetric hearing symptoms, focal neurological signs, or a first or worst-ever severe headache. Not required for textbook vestibular migraine presentations.

Vestibular function testing (video head impulse testing, vestibular evoked myogenic potentials, vestibular caloric testing) is ordered by ENT specialists or audiologists for diagnostic uncertainty and is Medicare-rebated under items 11340/11341/11343 with an eligible specialist referral.

Bloods: Thyroid function, full blood examination, and blood glucose are checked selectively to exclude other contributors to dizziness.

Key differentials — distinguishing vestibular migraine

Condition	How to tell it apart
BPPV	Seconds only, purely positional, classic torsional nystagmus on Dix-Hallpike, treated with Epley manoeuvre
Menière’s disease	Low-frequency hearing loss + aural fullness + tinnitus; 20 min – 12 h attacks
Vestibular neuritis	Single prolonged acute episode over days; abnormal head-impulse test to affected side
Posterior-circulation stroke / TIA	Sudden onset, HINTS-central pattern (normal head-impulse + direction-changing nystagmus + skew deviation), focal neurology — urgent
PPPD	Chronic non-spinning dizziness > 3 months, worsened by upright posture and visual motion environments
Orthostatic hypotension	Light-headedness on standing; blood pressure drop ≥20/10 mmHg

B. Understanding vestibular migraine attacks

Common triggers

Vestibular migraine attacks are frequently provoked by the same triggers as classic migraine headaches. Migraine & Headache Australia and clinical review evidence identify the most common:

• Sleep disruption — insufficient sleep or, equally, oversleeping
• Dehydration and skipped meals — irregular meal timing destabilises the brain’s metabolic state
• Stress — particularly the post-stress “let-down” period after sustained demands
• Hormonal fluctuation — perimenstrual attacks are particularly common in women; perimenopause often brings increased attack frequency
• Dietary triggers — alcohol (especially red wine), aged cheese, MSG, nitrates in cured meats, aspartame, and large changes in caffeine intake
• Sensory overload — busy patterned visual environments (supermarket aisles, traffic, scrolling screens), bright lights, and strong smells
• Weather and barometric pressure changes

A four-week prospective trigger diary helps identify personal patterns, since triggers vary significantly between individuals. The diary also captures attack frequency and severity to guide decisions about starting preventive treatment.

Why vestibular migraine happens — the biological connection

The migraine-vestibular connection reflects direct anatomical pathways linking the brainstem’s vestibular nuclei to the trigeminal sensory system involved in migraine. When trigeminovascular activation occurs — the hallmark of a migraine event — the resulting neuroinflammation and central sensitisation can extend to the vestibular system, producing vertigo and motion sensitivity alongside or instead of headache. The neurotransmitters involved (CGRP, serotonin) and the central sensitisation mechanisms are shared with classic migraine headache. This is why the same preventive and acute medications work for both conditions, and why lifestyle approaches that reduce overall migraine burden also reduce vestibular migraine burden.

The PPPD complication

An important consequence of undertreated vestibular migraine is progression to persistent postural-perceptual dizziness (PPPD) — a chronic non-spinning dizziness lasting more than three months, worsened by upright posture and visual motion environments. PPPD develops in roughly 30% of vestibular migraine patients who do not receive adequate management. It is an ICD-11 recognised entity requiring its own treatment (CBT, SSRI or SNRI, vestibular rehabilitation). Early recognition and treatment of vestibular migraine supports the brain’s own vestibular compensation process and helps the system establish stability.

C. Treatment options — acute and preventive

Acute attack management

Per eTG and AMH, the acute priorities are symptom relief and avoiding prolonged vestibular suppressants that would delay central compensation.

Non-pharmacological: Rest in a quiet darkened room; gentle hydration; minimise head movement that worsens vertigo.

Antiemetics and vestibular suppressants — for short courses only, up to 72 hours:

• Prochlorperazine 5–10 mg orally three times daily, or 12.5 mg by injection for severe nausea
• Metoclopramide 10 mg orally (caution: extrapyramidal effects, especially under age 30; limit duration strictly)
• Ondansetron 4–8 mg orally or wafer, particularly useful with severe vomiting

Triptans — when migrainous headache accompanies the attack, per Australian Prescriber:

• Sumatriptan 50–100 mg orally, 6 mg subcutaneously, or 20 mg nasal spray
• Rizatriptan 10 mg orodispersible (useful when nausea is prominent)
• Eletriptan 40 mg orally

The Cochrane 2022 review notes limited high-quality evidence for triptans specifically aborting vestibular symptoms; however, they are recommended when headache is present, extrapolated from migraine practice. Triptans are contraindicated in ischaemic heart disease, uncontrolled hypertension, and haemiplegic or brainstem-aura migraine.

Avoid prolonged vestibular suppressants. RACGP guidance and eTG are explicit: diazepam, prochlorperazine, and betahistine used beyond 72 hours actively delay the brain’s own vestibular compensation and should not be used as ongoing management of vestibular migraine.

Preventive treatment

Preventive medication is appropriate when attacks occur four or more times per month, when episodes cause significant disability, or when acute treatment provides inadequate relief. Per eTG and Australian Prescriber, the principle is to trial for 10–12 weeks at target dose before assessing response, and to maintain for 6–12 months before considering a gradual wean.

First-line options available in Australia:

Medication	Typical dose	PBS status	Best when
Propranolol	40–160 mg/day	General benefit	Comorbid hypertension or anxiety; avoid in asthma
Nortriptyline	10–50 mg nocte	General benefit	Comorbid tension headache, insomnia, or neuropathic pain
Amitriptyline	10–75 mg nocte	General benefit	Alternative to nortriptyline; more sedating
Topiramate	25–100 mg/day	PBS Authority Required (migraine prophylaxis, ≥18 years)	Weight loss is also a goal; avoid in women planning pregnancy
Candesartan	8–16 mg/day	General benefit (hypertension); off-label for vestibular migraine	Well tolerated; avoid in pregnancy
Venlafaxine	37.5–75 mg/day	General benefit (depression)	Comorbid depression or anxiety; equivalent to propranolol in one RCT (Salviz 2016)

The Brain 2022 vestibular migraine review confirms no single preventive agent is demonstrably superior — selection is based on your comorbidity profile, not a fixed first choice.

Lifestyle and non-pharmacological — cornerstone regardless of medication status:

• Regular, consistent sleep and wake times; addressing any obstructive sleep apnoea
• Regular meal timing and adequate daily hydration
• Regular aerobic exercise (aim for ≥150 minutes per week at moderate intensity)
• Four-week trigger diary; targeted avoidance of identified personal triggers
• Vestibular rehabilitation therapy (see below)

Vestibular rehabilitation therapy (VRT): Referral to a vestibular physiotherapist is recommended for moderate-to-severe vestibular migraine. An 8–12-week programme of habituation exercises, gaze stabilisation, and balance retraining supports central vestibular compensation and reduces dizziness-related disability. Studies by Sugaya (2017) and Vitkovic (2013) demonstrate meaningful reductions in Dizziness Handicap Inventory scores and attack frequency when VRT is combined with medical management. Referral can be coordinated through a GP Chronic Condition Management Plan (GPCCMP), enabling Medicare-rebated allied health follow-on visits.

Monitoring during preventive therapy

A vertigo and headache diary recording attack days, duration, severity, suspected triggers, acute medication use, and — for women — menstrual timing is essential for tracking progress. Review with your GP at six weeks for tolerability and dose adjustment, then at 12 weeks for an efficacy decision. A meaningful response is generally considered to be at least 50% reduction in monthly vertigo days or a clinically significant improvement in dizziness handicap scores.

D. Australian operations

MBS rebates

Vestibular migraine management in general practice uses standard consultation items: Item 23 (Level B, 6–20 min), Item 36 (Level C, 20–40 min), and Item 44 (Level D, ≥40 min). Telehealth equivalents apply with an established 12-month patient–GP relationship.

For patients with chronic vestibular migraine and comorbidities (anxiety, depression, balance impairment, or multiple conditions), a GPCCMP (Item 965/967) enables coordinated care with vestibular physiotherapy, psychology, and dietitian under Medicare-rebated allied health visits. Comorbid anxiety or depression may be addressed via a Mental Health Treatment Plan (Item 2715/2717) for psychology sessions. Specialist referral uses standard attendance items 110 (initial) and 116 (subsequent) for neurologist or ENT.

Vestibular function testing — video head impulse testing, vestibular evoked myogenic potentials, VNG caloric testing — is Medicare-rebatable under audiology items 11340/11341/11343 (updated March 2023) with an eligible specialist referral.

PBS access for medication

Most preventive medications are available under PBS general benefit: propranolol, nortriptyline, amitriptyline, venlafaxine, and candesartan. Topiramate requires a PBS Authority for migraine prophylaxis in adults aged 18 or over. Triptans for acute attacks are PBS Streamlined Authority under the migraine indication — sumatriptan, rizatriptan, eletriptan, and zolmitriptan are all available.

Flunarizine: Despite being internationally first-line for vestibular migraine, flunarizine is not registered on the ARTG and has no PBS listing in Australia. It is available only through the TGA Special Access Scheme Category C. Your GP or neurologist lodges the SAS-C notification, and a compounding or importing pharmacy supplies it at full out-of-pocket cost. Migraine Australia documents the access pathway. This access barrier is worth knowing if you have read international vestibular migraine guidelines that recommend flunarizine prominently.

CGRP monoclonal antibodies (fremanezumab, galcanezumab, eptinezumab) — emerging evidence for vestibular migraine exists but these agents are not PBS-listed for this specific indication. Access via the chronic migraine PBS pathway requires ≥15 headache days per month for ≥6 months and ≥3 prior preventive failures — a threshold many vestibular migraine patients do not meet. Discuss with your neurologist if relevant.

E. Special populations

Women — hormonal considerations

Vestibular migraine affects women approximately three times more often than men. Attacks frequently cluster around the menstrual cycle — the perimenstrual and ovulation phases are particularly high-risk — and perimenopause often triggers increased attack frequency as oestrogen fluctuation intensifies. Perimenstrual attacks may be amenable to mini-prophylaxis strategies (a short course of naproxen or frovatriptan around the expected high-risk days). Discuss hormonal factors openly with your GP, particularly if you are approaching perimenopause, where menopausal hormone therapy decisions intersect with migraine and vestibular management.

Pregnancy

During pregnancy, pharmacological options are substantially restricted. Paracetamol is first-line for acute attacks. Sumatriptan has the most reassurance data of the available triptans in pregnancy. For prevention, propranolol or low-dose nortriptyline are generally preferred in consultation with your GP. Avoid topiramate (associated with cleft palate in the foetus), avoid sodium valproate (TGA black box warning for developmental outcomes), and avoid candesartan (foetal risk in the second and third trimesters). CGRP antibodies and gepants have no human pregnancy safety data and are not used. Non-pharmacological approaches — vestibular rehabilitation, trigger management, sleep stabilisation — take on particular importance.

Older adults

Vestibular migraine in older adults can be harder to identify because migrainous features become less prominent and headache may be absent entirely. The condition also coexists with BPPV, which should be identified and addressed as a separate problem. Falls risk is significant, and medication selection must account for cardiovascular factors, cognitive safety, and polypharmacy — minimise central sedation and avoid prolonged vestibular suppressants.

Driving and fitness to drive

Austroads (Assessing Fitness to Drive 2022) classifies recurrent or disabling vertigo as conditional on satisfactory control. If your attacks are frequent and not yet well managed, your GP may need to provide guidance on driving restrictions and, in some circumstances, notify the driver licensing authority. Commercial vehicle standards are stricter than private vehicle standards. Document that driving advice has been discussed.

When to escalate

Refer urgently (same day or emergency) when any episode involves:

• Sudden severe (“thunderclap”) headache — worst headache of life
• New weakness, numbness, speech disturbance, or double vision
• Sudden hearing loss (steroid window is within 14 days — same-day ENT is ideal)
• HINTS examination positive for central pattern: normal head-impulse, direction-changing nystagmus, positive skew deviation
• Vertigo after head or neck trauma

Refer routinely to neurology or neuro-otology for:

• Diagnostic uncertainty after a reasonable general practice assessment
• Failure of two or more first-line preventive agents
• Atypical features — progressive course, asymmetric hearing loss, haemiplegic or brainstem aura
• Suspected chronification to persistent postural-perceptual dizziness

Refer to ENT for audiometric abnormality, asymmetric tinnitus or hearing loss, or suspected Menière’s disease.

Refer to vestibular physiotherapy for all patients with moderate-to-severe functional impact or ongoing balance impairment — this referral does not need to wait for diagnostic certainty.

What this article is and is not

This is general health information drawn from Australian general practice guidelines — eTG, AMH, Australian Prescriber, RACGP, Migraine & Headache Australia — and major international vestibular migraine evidence including the Bárány Society/ICVD diagnostic criteria, the Cochrane 2022 pharmacological interventions review, and the Brain 2022 treatment review. It is not personal medical advice and does not create a doctor–patient relationship. Decisions about investigation, diagnosis, and treatment are made in partnership with your own GP and treating clinicians, taking your full health history into account.

For consumer-friendly information: HealthDirect — Vertigo and dizziness, Migraine & Headache Australia — vestibular migraine, Better Health Channel — Migraine.

For urgent care: if you experience sudden severe symptoms suggesting stroke — including new weakness, speech change, or vision loss alongside vertigo — call 000 immediately.

---

Sources cited

1. Migraine & Headache Australia — Vestibular migraine
2. Bárány Society / ICVD — Vestibular migraine diagnostic criteria (Lempert 2012)
3. ICHD-3 — A1.6.6 Vestibular migraine
4. Therapeutic Guidelines (eTG) — Neurology
5. Australian Prescriber — Migraine management (Stark 2024)
6. Australian Medicines Handbook (AMH)
7. RACGP AJGP — Vertigo in general practice
8. HealthDirect — Vertigo and dizziness
9. Better Health Channel — Migraine
10. Brain 2022 — Vestibular migraine treatment review
11. Cochrane 2022 — Pharmacological interventions for vestibular migraine
12. Salviz et al. — Propranolol vs venlafaxine in vestibular migraine (Laryngoscope 2016)
13. Sugaya et al. — Vestibular rehabilitation in vestibular migraine (2017)
14. Vitkovic et al. — Vestibular rehabilitation in vestibular migraine (2013)
15. Migraine Australia — Flunarizine and the tool box
16. Migraine Australia — CGRP therapies
17. TGA — Special Access Scheme Category C lists
18. TGA — Valproate safety alert
19. Austroads — Assessing Fitness to Drive 2022
20. Services Australia — GPCCMP MBS billing rules
21. MBS items: 23 · 36 · 44 · 110 · 116 · 965 · 967 · 2715 · 2717 · 11340 · 11341 · 11343