Vestibular migraine (VM) is a migraine disorder characterised by the overlapping presence of vestibular and migraine symptoms, which may include vertigo, loss of balance, visual disturbances, headache, sensitivity to sound and light, or visual aura. Whilst benign paroxysmal positional vertigo (or BPPV - an inner ear disorder) causes vertigo more frequently, vestibular migraine is actually the most common cause of spontaneous episodic vertigo. Despite this, it is a poorly understood and largely underdiagnosed condition. (1, 2)
Using the Watson Headache ® Approach we are able to identify a key fault that feeds both migraine and vestibular symptoms and provides a key bridge to the two different areas. Whilst many other clinics will have barely heard of vestibular migraine, our experience and expertise at the Melbourne Headache Centre allows us to identify a key cause and treat it rapidly, safely and effectively.
Vestibular Migraine Causes
Like other forms of migraine we have an incomplete understanding of the pathophysiology of vestibular migraine, but several mechanisms link the trigeminal system, which is active during migraine attacks, and the vestibular system (3).
The most important of these mechanisms providing the strongest link between the trigeminal and vestibular system relates to a group of small muscles under the base of your skull.
These muscles (known as the sub-occipital muscles) play a major role in coordinating head and eye movements and finely controlled movements of the head with the trunk. To do this they are jam packed with muscles spindles - the sensory part of the muscle. In fact they have the highest muscle spindle density of any muscle group in the body. Pictured here is obliquus capitus inferior (OCI), which has over 250 spindles per gram of muscle tissue. The small muscles in our hand (considered to be very sensitive giving us great dexterity) have around 20 spindles per gram of tissue. (4)
In response to our typical head forward and head down neck postures we see OCI having a strong protective response, tightening up to help protect the upper cervical segments. Whilst this sounds quite minor, the effect on our brainstem can be quite explosive.
Pictured here is C2, C3 and C4 rotated to the left of picture, caused by a tightening of obliquus capitus inferior. The impact in these segments is a bit like bending your finger back as far as it will go and keeping it there. Lots of stretch, with the associated pain and inflammation.
OCI also connects directly to the dura - the soft tissue that covers the spinal cord and brain - and strongly suspected as the source of inflammation in migraine (5) - if this muscle is tight and pulling on the dura it can directly caused the inflammation associated with migrainous symptoms. Rather than take drugs to combat the inflammation, treating this muscle is the best place to start treatment! The amount of 'noise' created in the trigemino-cervical complex in this case is immense. Exactly what we see as a hallmark of migraine - underlying and constant 'noise' in the trigemino-cervical complex. Using the Watson Headache ® Approach we are able to correct the pressure that OCI is reacting to. We see this position correct in about 30 seconds or so during the assessment, and can show you how to keep it stable. Properly identifying and treating the cause for this muscle spasm is a critical step that is often missed, and has a profound effect on the response to treatment.
NB: In the hands of a skilled practitioner this fault is able to be assessed manually. If you have x-rays by all means being them to the assessment, but they are not required to identify this fault, and cause needless exposure.
Vestibular Migraine Treatment - Physiotherapy: The Watson Headache ® Approach
During the assessment we are looking for three key factors:
Do you have a small fault which creates spasm in OCI?
Can we treat the fault and correct the muscle spasm?
Is it relevant to your condition?
The Watson Headache ® Approach deals with a small fault in the top of the spine which creates a spasm in OCI. Properly identifying and treating the cause for this muscle spasm is a critical step that is often missed, and has a profound effect on the response to treatment. At the Melbourne Headache Centre, we specialise in providing treatment for vestibular migraine we are used to treating people with chronic issues and sensitive necks. We understand that many of our clients seeking treatment for vestibular migraine may have been aggravated with the ‘press and guess’ approach some standard manual therapies employ. Treating OCI is not usually about ‘deep and painful’ manual stretching techniques. By treating the source of the spasm we can do so with minimal aggravation and maximum impact, and it’s also the reason why we typically see rapid changes with vestibular migraine, and often don’t need to do a lot in terms of hands on treatment. Many people have this fault in the top of the neck. If you are sensitive to the ‘noise’ it creates you will potentially have symptoms associated with headache, migraine or some of its variations including vestibular migraine.
Vestibular migraine is a migrainous disorder characterised by the presence of vestibular and migrainous symptoms which may include vertigo, loss of balance, visual disturbances, headache, sensitivity to sound and light, or visual aura. Vestibular migraine, like other primary headache disorders such as migraine, migraine with aura and tension-type headache will be diagnosed when other known cause for vestibular symptoms, such as BPPV or Meniere's disease are ruled out.
The International classification of headache disorders version 3 (ICHD-3) describes vestibular migraine as: Episodes characterised by the presence of one of a number of possible vestibular symptoms of moderate to severe intensity (i.e. interferes with daily activities) lasting 5 minutes to 72 hours:
Spontaneous vertigo
Internal (false sense of self-motion)
External (false sense that the visual surroundings are spinning or flowing)
Positional vertigo
Visually-induced vertigo, triggered by things moving in the visual field
Head-motion induced vertigo
After you have had at least 5 episodes of the above, and at least half of them are accompanied by at least one typical migrainous feature such as:
Headache with at least two of:
Unilateral location
Pulsating quality
Moderate or severe intensity
Aggravation by routine physical activity
Photophobia and phonophobia
Visual aura
If 5 episodes have occurred with at least some of the above occuring in different episodes (not all symptoms need to be present all the time) then a diagnosis of vestibular migraine will be given.
Vestibular Migraine Differential Diagnosis - What else could it be?
BPPV - Benign paroxysmal positional vertigo. VM comes in at second as a cause of vertigo - this is number one. This is a more common presentation and should be ruled out by testing with a vestibular (ENT) specialist or Physiotherapist specialising in vestibular therapy.
Meniere’s disease - a condition with recurrent vertigo accompanied by fullness or ringing in the ears (tinnitus) and deafness. Symptoms include vertigo, dizziness, nausea, vomiting, loss of hearing (in the affected ear), and abnormal eye movements. It is caused by dysfunction of the semi-circular canals of the inner ear.
More acute causes should be ruled out with MRI at the onset of new symptoms, such as a brain tumour or Multiple Sclerosis.
References
Lempert, T. and Neuhauser, H. (2009) Epidemiology of vertigo, migraine and vestibular vertigo. J Neurol 256: 333338.
Neuhauser, H.K., Radtke, A., von Brevern, M., Feldmann, M., Lezius, F., Ziese, T. et al. (2006) Migrainous vertigo: Prevalence and impact on quality of life. Neurology 67: 10281033.
Lempert, T. von Brevern, M. and Lanska, D. J. (2019) Vestibular Migraine. Neurology, Medlink
Kulkarni V, Chandy M, et al. Quantitative study of muscle spindles in suboccipital muscles of human foetuses. Neurology India 2001;49: 355–9.
Boldingh, MI. Ljostad, U, Mygland, A. and Monstad, P (2013) Comparison of interictal vestibular function in vestibular migraine vs migraine without vertigo. Headache, 2013, Jul-Aug; 53 (7): 1123-33.
Espinosa-Sanchez, J and Lopez-Escamez J. A. (2015) New Insights into Pathophysiology of Vestibular Migraine. Frontiers in Neurlogy
International Classification of Headache Disorders - version 3.
