Vestibular Migraine

What Vestibular Migraine Is

The first thing to understand is that migraine is not simply a severe headache. While many people with migraine do experience headache as one of the classical symptoms, vestibular migraine often produces no headache at all, or only a mild headache that patients barely notice compared to their other symptoms. This is one of the major reasons it is missed for years.

Symptoms of Vestibular Migraine

Symptoms are varied and can include:

• Tiredness — often overwhelming and out of proportion to activity.
• Dizziness or vertigo — a spinning sensation, or a feeling of the floor moving.
• Nausea — with or without vomiting or diarrhoea.
• Inability to concentrate — looking at computer or television screens becomes particularly difficult; sometimes even reading a book feels overwhelming.
• Sensitivity to light, sound or smell — making you want to curl up in a dark, quiet room away from all stimulation.
• Headache — sometimes surprisingly mild in vestibular migraine despite the severity of other symptoms.
• Neck and shoulder stiffness.
• Visual disturbances — blind spots, distorted vision, flashing lights or zigzag patterns.
• Tingling or stiffness in the arms or legs.
• Difficulty speaking or finding the right words.
• Very rarely paralysis or loss of consciousness — exceptionally uncommon.

Recognising Your Aura

Over time, many people with migraine become able to identify symptoms that consistently occur immediately before an attack begins. This warning period is the aura, and recognising it is one of the most useful skills a migraine sufferer can develop. Common aura symptoms include:

• Cravings for certain foods (particularly sweet things).
• Tiredness and excessive yawning.
• Excitability or hyperactivity.
• A change of mood — often very hard to recognise about yourself; try listening to those around you, who may notice you becoming irritable or withdrawn before you do.
• Any of the vestibular migraine symptoms above occurring in a milder form before intensifying.

Being able to identify your aura is extremely useful because at this point an attack is often potentially reversible if you act immediately. Most people find they need to head straight to a quiet dark room to sleep in order to avoid a full-blown attack. This rapid response can be the difference between a mild episode that passes quickly and several days of debilitating symptoms.

Trigger Factors

Not everyone has an identifiable aura. For those without one, understanding personal trigger factors becomes crucial.

Emotional stress

Anger, tension, worry, shock — and interestingly even positive excitement — can all trigger migraine.

Physical stress and sleep changes

Over-exertion and tiredness are major triggers. Late nights or significant changes in sleep pattern are particularly common precipitants. This is especially upsetting for people travelling long-haul, as jetlag can ruin what should be a lovely holiday.

Food triggers

Food triggers are numerous and somewhat individual. The most commonly implicated are:

• Citrus fruits
• Onions
• Seafood
• Marmite
• Cheese and other dairy products
• Pork
• Chocolate
• Aspartame (artificial sweetener)
• Wheat
• Alcohol (particularly red wine, sherry or beer)
• Monosodium glutamate (widely used in prepared meals and takeaway food)

I do not recommend embarking on strict exclusion diets that eliminate all of these simultaneously — it makes life miserable and is often unnecessary. Most patients gain far more benefit from moderating overall food intake and carefully regulating meal times. Avoid long gaps between meals and any diets that involve fasting or skipping meals — low blood sugar is itself a potent migraine trigger. If careful meal timing does not prevent attacks, then it may be worth excluding one food type at a time, particularly if you have noticed that specific food seems to worsen your symptoms.

Drinks, caffeine and hydration

Avoiding dehydration is absolutely key. Caffeine deserves particular attention. Caffeine causes changes in cerebral blood flow, and altered cerebral blood flow is one of the mechanisms thought to underlie migraine. If you drink a great deal of coffee or tea during the day and then none overnight, this represents a substantial change in brain blood flow that has been implicated in triggering attacks. If possible, heavy caffeine users should either stop completely or cut down to an absolute minimum. Conversely, people who do not normally consume caffeine often find painkillers with added caffeine helpful during an attack — this does not work for established heavy caffeine users. Note also that caffeine is mildly dehydrating, so a cup of tea is roughly minus a glass of water rather than hydrating you.

Environmental triggers

• Bright or flickering lights — fluorescent tube lighting common in offices and supermarkets is often particularly difficult.
• Loud noise.
• Strong smells, including cigarette smoke.
• Stuffy, poorly ventilated rooms.

Hormonal changes

Hormonal changes affect migraine significantly, which is why women are far more frequently affected. The menstrual cycle, the combined oral contraceptive pill, pregnancy, and menopause all represent periods of hormonal fluctuation that can trigger or worsen migraine. Hormonal changes during puberty affect both boys and girls.

Other less common triggers

• Blocked nose, sore throat, toothache.
• Sleeping tablets.
• Chronic neck, back and eye strain — common in people sitting at poorly designed computer workstations all day. These patients are often bombarded with multiple triggers simultaneously, making management especially difficult.

Managing Vestibular Migraine

Managing migraine is extremely difficult to give generalised advice about, because everyone's migraine is different. Treatment needs to be highly individualised. My general approach is to avoid anti-migraine medication where possible, and instead encourage patients to identify their own specific trigger factors and aura symptoms using the framework above. Being able to alter your lifestyle to prevent attacks is infinitely preferable to relying on lifelong medication, many of which carry unpleasant side effects including drowsiness, weight gain and cognitive dulling.

Keep a migraine diary

I strongly urge a detailed migraine diary so you can better understand your own condition and hopefully prevent symptoms long-term through pattern recognition. The most important elements to record each day are:

• Time you went to bed and woke up.
• Meal times throughout the day.
• Particular foods eaten (if you can manage it).
• Stress levels.
• Any migraine symptoms, however mild.
• Other trigger factors above that you were exposed to.

Be aware that there is often a considerable lag time between certain triggers and symptoms. For example, people who have cheese as a trigger when eating it late at night may only notice resulting migraine symptoms three or four days later — making the connection extremely hard to identify without careful diary keeping. After every full-blown attack, be as analytical as possible about the onset: what your aura symptoms may have been, which possible trigger factors you were exposed to in the preceding days.

Managing an acute attack

At the very first sign of symptoms, go to a quiet dark room and sleep as much as possible. If you have a severe headache making it difficult to fall asleep, simple analgesia — paracetamol or ibuprofen, with or without added caffeine — is a reasonable first step. Some people also have significant nausea that makes falling asleep extremely difficult and prolongs their suffering. If this applies to you, please let me know and I can provide anti-nausea medication to use as required during attacks.

Chronic "grumbling" symptoms

Many people with vestibular migraine experience symptoms that grumble on for months with occasional acute episodes superimposed. Because this can persist so long, it often becomes very difficult to remember what normal life actually felt like before symptoms began. I recommend a prolonged period of consciously avoiding eye strain of any kind, sleeping as much as your schedule allows while still maintaining a regular sleep-wake cycle, and remaining in a quiet, stress-free environment for as long as possible. Avoid television, minimise time on computer and phone screens, and avoid reading books or magazines during the recovery period. Maintain regular meal times without skipping, and consider reducing refined sugar. Re-read the section on caffeine and consider whether it could be a significant trigger for you. Once you have truly regained what you believe represents normal functioning, it becomes much easier to notice the return of symptoms early and to intervene before they become severe.

Booking and Next Steps

If you would like to see me again about this condition, I am happy to do so — the secretarial team can arrange a consultation. Managing vestibular migraine is challenging, and joining migraine support groups to share experiences with others who understand what you are going through can be enormously helpful. See also BPPV & Vertigo, Hearing Loss, and Tinnitus — conditions that sometimes coexist with vestibular migraine.