Vestibular Migraine: Dizziness and Vertigo Without the Headache

Vertigo that arrives in episodes, runs for minutes or hours, and leaves nothing behind for a doctor to find is often migraine. Vestibular migraine is the name for it. The part that keeps people from recognizing their own condition is that the head pain is frequently absent: in a German population study, only 24% of people with migrainous vertigo always had a headache during their attacks. For the rest, the dizziness is the attack.

Formal diagnostic criteria exist for it, along with a defined duration window and a wide documented gap between how common the condition is and how often it gets named. Below is what the research establishes and where the evidence stops. One thing first: dizziness that is sudden, new, or arrives alongside hearing loss, weakness, or trouble speaking is a same-day medical question, not a reading question.

What vestibular migraine is

Two bodies wrote the criteria jointly: the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society. Lempert and colleagues published them in the Journal of Vestibular Research in 2012.

Those criteria now sit in the appendix of the International Classification of Headache Disorders, third edition, as entry A1.6.6. That appendix placement is procedural rather than a verdict on whether the condition is real. New entities enter the appendix first under standard IHS practice, as a staging area while evidence accumulates.

The framing matters more than the paperwork. In vestibular migraine the vestibular symptoms are the attack, not a footnote attached to a headache. Someone can have a decade of these episodes, a completely normal ear exam, and a migraine history that nobody connected to the dizziness.

The criteria, in plain terms

At least five episodes. One bad afternoon does not meet the definition. ICHD-3 requires five, which is part of why the diagnosis is so often delayed: the pattern has to exist before it can be recognized.

A migraine history, current or past. The person needs a history of migraine without aura or migraine with aura. Past counts. Headaches that stopped years ago still satisfy this criterion, which catches people who assume their migraine days are behind them.

Five minutes to 72 hours, moderate or severe. Vestibular symptoms are rated moderate when they interfere with daily activities and severe when daily activities cannot continue. Qualifying symptoms include spontaneous vertigo, positional vertigo, vertigo triggered by large moving visual scenes, vertigo brought on by head motion, and head motion dizziness with nausea.

Migraine features in at least half of episodes. Half of the episodes must carry at least one of three things: a headache with at least two of four migraine characteristics (one sided, pulsating, moderate or severe, worsened by routine activity), or photophobia together with phonophobia, or visual aura.

Nothing else explains it better. A last criterion asks that no other ICHD-3 diagnosis or vestibular disorder accounts for the episodes. This is where the workup goes, and it is why the diagnosis stays clinical.

The headache is often missing

Neuhauser and colleagues screened a representative sample of 4,869 German adults for moderate or severe dizziness, then ran validated telephone interviews with 1,003 of them. Their 2006 Neurology paper put the lifetime prevalence of migrainous vertigo at 0.98% and the 12 month prevalence at 0.89%.

Inside that group, 67% reported spontaneous rotational vertigo and 24% had positional vertigo. The number that reframes the condition is the other 24%: only about a quarter of participants always experienced headaches with their vertigo. Three quarters had at least some episodes where the pain never showed up.

People who have read about aura without headache will recognize the shape of this. Migraine is a neurological event that can express itself through several systems, and the head pain is one output among several rather than the definition of the disorder.

How long an episode lasts

ICHD-3 is unusually candid that duration varies widely. Roughly 30% of patients have episodes lasting minutes, about 30% have attacks lasting hours, and another 30% have attacks that run over several days. A final 10% have attacks of seconds, recurring during head motion or after position changes, and for those the episode is counted as the whole period over which the short attacks repeat.

There is a tail worth knowing about. Some people take up to four weeks to recover fully from an episode, even though the core episode rarely exceeds 72 hours. A recovery that drags is not evidence that the diagnosis is wrong.

Why it takes so long to get named

The Neuhauser study measured this directly. Two thirds of participants with migrainous vertigo had consulted a doctor about it. Of those who did, only 20% received the diagnosis. Four out of five people who sought help for the problem left without a name for it.

Two things drive that. The first is the missing headache: a patient who reports dizziness and no pain does not look like a migraine patient to anyone working from the stereotype. The second is that objective findings are inconsistent, so the tests that feel most authoritative tend to come back normal. Diagnosis rests on a history of episodes, and histories reconstructed from memory in a short appointment are thin.

A cost to quality of life shows up regardless. Neuhauser's group found health related quality of life scores consistently lower in participants with migrainous vertigo than in dizziness free controls, after adjusting for age.

What it is not

Not a migraine aura. Only a minority of people with vestibular migraine have vertigo inside the 5 to 60 minute window that defines an aura symptom, and fewer still have it immediately before the headache begins. ICHD-3 is explicit that these episodes cannot be classed as auras.

Not migraine with brainstem aura. Vertigo is reported by more than 60% of patients with brainstem aura, so the overlap is easy to assume. But brainstem aura requires at least two brainstem symptoms alongside visual, sensory, or speech aura, and fewer than 10% of vestibular migraine patients meet that bar.

Not benign paroxysmal positional vertigo. BPPV attacks last under a minute and are reliably provoked by specific head position changes. Von Brevern and colleagues put its lifetime prevalence at 2.4% in the same German population work, and found migraine independently associated with BPPV, which means the two conditions coexist often enough that having one does not rule out the other.

What people report as triggers

Chae and colleagues followed 54 adults with vestibular migraine at a single university clinic, mean age 47.0, and published the results in the Journal of Vestibular Research in 2022. Patients with more than 15 dizzy days per month averaged 8.7 triggers compared with 6.4 for those with episodic symptoms.

The specific triggers separated the two groups. Motion was named by 93.9% of the chronic group against 66.7% of the episodic group, scrolling on a screen by 78.8% against 47.6%, and a skipped meal and air travel by 57.6% against 23.8% each. This is one small single center cohort, so treat the percentages as a map of what to watch for rather than a settled ranking.

What to write down

Every criterion above is a counting problem. Five episodes, each between five minutes and 72 hours, at least half accompanied by a migraine feature. Nobody reconstructs that from memory, and the appointment where it matters usually lasts fifteen minutes.

I do not get migraines. My mom and my wife both do, and this site exists because of them, so the parts I understand best are the ones I watched them struggle with. The hardest was always the appointment: sitting across from a doctor trying to remember how many episodes there had been since the last visit, and how long each one ran. Neither of them could ever do better than a shrug.

So log each episode when it happens, with the date, the start and end time, and whether any migraine feature came with it. Note what preceded it, since trigger tracking only works when the record is contemporaneous.

Some tracking apps treat an attack as a single undifferentiated event. MigrAid logs prodrome, attack, and postdrome as distinct stages and exports the history as PDF or CSV over a date range you choose, so what you hand a neurologist is a dated record instead of a recollection. That is also the most useful thing to bring when you prepare for a neurology appointment.

When to bring it to a doctor

Persistent or worsening vertigo belongs in front of a clinician, full stop, and so does any first episode. The criteria exist to be applied by someone who can also rule out the alternatives, and the last ICHD-3 criterion is precisely the one a patient cannot check alone.

Some presentations need urgency rather than an appointment in a few weeks. Sudden severe vertigo with new hearing loss, double vision, weakness, numbness, or difficulty speaking needs emergency assessment, because those combinations point away from migraine. A vertigo episode that behaves differently from your usual pattern deserves the same caution as a headache that behaves differently from your usual pattern.

The bottom line

Vestibular migraine is a defined condition with published criteria, a lifetime prevalence near 1%, and a diagnosis rate of 20% among the people who ask a doctor about it. Episodes run from five minutes to 72 hours, the headache is absent in most people at least some of the time, and the tests usually come back clean.

If that pattern sounds like yours, the useful next step is not self diagnosis. It is a record: dates, durations, and what else came along. Bring that to a doctor, and the conversation starts from evidence rather than from a description of how bad last month felt.