Vestibular migraine and spontaneous vertigo – Migraine Associated Vertigo

Ross Hauser, MD

This article continues and provides further discussion and information on cervical vertigo. Please refer to Cervical Vertigo and Cervicogenic Dizziness from more discussion, patient cases and treatment options for problems of dizziness.

When people come into our offices with a problem of Vestibular migraine, spontaneous vertigo or Migraine Associated Vertigo they talk to us about a very long medical journey they have taken that no one can quite understand. This includes family and the medical professionals that these people have seen already looking for help and support. If their stories are similar to your story, you will know that these people spend a lot of time looking for the triggers that cause the “silent migraine” a headache free migraine and the sudden, spontaneous vertigo that comes with it.

Here are some of the things we have heard from our patients:

My doctor sent me to a nutritionist. We did allergy food testing, which I was sensitive for a few things. I was told no sugars and no caffeine because in addition to the dizziness I would suffer from sudden onset panic attacks and of course this whole problem with my health health leaves me pretty much exhausted with stress and anxiety. 

I am still on the diet, I think it has helped somewhat, but I still get these symptoms of migraine aura and then dizziness. They even come to me in my dreams. 

I have been on Verapamil, it helps a little. My doctor thinks it would work better if I had symptoms of Meniere’s Disease. I do have a sway to me. 

Treatments for me up until this point have not been successful. Things do not work for me long-term. At this point I would be grateful if something worked for me short-term. As my symptoms got worse I would get more diagnosis and more medications. I started to get confused as to whether my worsening symptoms were the result of side effects from these medications or new manifestations. 

I thank god that I am still somewhat functional and that I have a supportive husband. I am also grateful that these attacks seem to have been less dramatic and less frequent, however they are still there in the back of my mind. I wish I had answers. 

If this story sounds familiar to you and you are also searching for answers, this article will present one possible answer for you. That your symptoms are being caused by cervical neck instability and physical problems in your cervical spine manifesting themselves in vestibular migraine and spontaneous dizziness. Let’s look at supportive research.

“Vestibular migraine is the most common cause of spontaneous vertigo but remains poorly understood.”

Poorly understood is a recurrent them when it comes to patients with Vestibular migraine and spontaneous vertigo

Stat Pearls is a publication of the National Center for Biotechnology Information, U.S. National Library of Medicine. In the article Migraine-Associated Vertigo (Vestibular Migraine) (1), Daniel B. Hilton and Carl Shermetaro of McLaren Oakland Hospital write of the complication surrounding the understanding of Vestibular migraine and spontaneous vertigo. This may explain why your health care providers are looking for answers for you.

  • “Patients explain a sensation of motion when no motion is taking place or an altered sensation with normal motion to define vertigo. In a vestibular migraine, the sensation is often described as a “to-and-fro” (backwards and forwards) sensation, and this can complicate diagnosis. Simultaneous headaches do not always accompany the vestibular symptoms, thus making an in-depth history and multi-specialty evaluation pivotal in order to make a diagnosis.”
  • “Current management of a vestibular migraine consists of conventional migraine management as there is currently no accepted specific treatment for this disease. Additionally, convincing a patient of the diagnosis can prove difficult and lead to a delay in treatment or absence of treatment. This is understandable based on the fact that vertiginous symptoms are often asynchronous (happening at same time) with a headache and maybe a difficult connection for the practitioner or patient to grasp.”

A study published in October 2019, lead by researchers at Massachusetts Eye and Ear Infirmary, Harvard Medical School, and Ohio State University  examined Vestibular migraine as one of  the most common cause of spontaneous vertigo and why this problem remains poorly understood. The study was published in Scientific reports (2).

Here are the learning points:

  • “Vestibular migraine is the most common cause of spontaneous vertigo but remains poorly understood.”
  • The researchers investigated the hypothesis that central vestibular pathways (dysfunctions of the body’s system to maintain balance) are sensitized (heightened) in Vestibular migraine by  the vestibulo-ocular reflex (VOR) and vestibular and headache symptom severity.

We are going to move away from this research for some brief understanding notes and then we will return:

  • The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment).
    • It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism.
      • In human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.
The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. In human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady," to prevent motion from creating dizziness or sway.

The vestibular system is the body’s sensory system that regulates balance and spatial orientation (the understanding of where you are in your environment). It sits in the inner ear and works by adjusting fluid levels that act as the balance mechanism. In human beings, we set our awareness of our place in space by using the ground as the constant place of orientation. We can keep our balance when we walk because we understand the ground is the constant and our vestibular system makes constant involuntary adjustments to “keep things steady,” to prevent motion from creating dizziness or sway.

Returning to the study

  • Vestibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)
  • The researchers suggest a pathogenic model where vestibular symptoms emanate from the vestibular nuclei, (the the cranial center point for the vestibular nerve) which are sensitized by migraine-related brainstem regions and simultaneously suppressed by inhibitory feedback from the cerebellar nodulus and uvula, the site of canal-otolith integration.

The suggestion is simply, something is happening to the vestibular nerve which is overly sensitized to pain by the reaction of something happening to the brainstem and the process is further sent into panic by a dysregulation of the function of the balance mechanism in the ear.

It's an ear problem, not a Ménière's disease problem. estibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere's Disease type problem.)

It’s an ear problem, not a Ménière’s disease problem. Vestibular migraine patients were abnormally sensitive to roll tilt (a misalignment of the eyes disrupting sense of gravity and space), which co-modulates semicircular canal and otolith organ activity (this is an ability to sense gravity and sense motion), but not to motions that activate the canals or otolith organs in isolation (where fluid in the ears stabilizers balance), implying sensitization of canal-otolith integration. (Something is off but it is not a Meniere’s Disease type problem.)


Why does the treatment protocol include antidepressants, antiepileptics, beta blockers, and physical therapy? Some may find this treatment successful. People with neck pain and instability may not.

As we are quick to point out. Many people do well with some many treatments fro vestibular migraine and spontaneous vertigo. People who do well with medications are typically not the people we see in our office. Medications do not work for everyone.

Let’s examine a May 2020 study (3) from the Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina. In this study researchers sought to identify patient factors that influence response to therapy in patients with vestibular migraines. In other words, what could make treatment work better, what factors would predispose a patient to a less than optimal response to treatment.

  • 47 patients evaluated for treatment of definite vestibular migraine
  • Interventions: A protocol of antidepressants, antiepileptics, beta blockers, and vestibular rehabilitation. Patients failing initial therapy received botulinum toxin per the PREEMPT (before the migraines start) protocol. Vestibular rehabilitation (physical therapy to to improve balance and problems related to dizziness.)

What happened to the 47 patients?

  • Of the 47 patients who underwent therapy for vestibular migraine. This population had a significant dizziness handicap inventory (a measuring score) reduction with therapy.
  • This worked especially better for women, patients with comorbid benign paroxysmal positional vertigo, and high initial dizziness handicap inventory were significantly associated with greater reduction in dizziness handicap inventory scores.

Neck pain and oscillopsia did not respond as well

  • Conversely, cervicalgia and oscillopsia were significantly associated with a lower reduction in dizziness handicap inventory scores.

Is neck pain and cervical spine instability a possible cause of your vestibular migraine and spontaneous vertigo – migraine associated vertigo?

We suggest one possible answer for this, not the only one. We feel and examination of cervical spine instability may lead to answer.

When there is pressure on the brain stem, and this pressure can be exerted by hypermobility of the cervical spine vertebrae, this can result is health problems or diseases of the brainstem which can result in abnormalities in the function of cranial nerves. This would be the problems we spoke about earlier surrounding visual disturbances, pupil abnormalities, vestibular and headache symptom severity, hearing problems, vertigo, swallowing difficulty, among other challenges. In our case we may explore what is happening throughout the cervical spine with attention to cervical  vertebrae where Cranial Nerve VIII (Vestibulocochlear nerve) comprised of the cochlear nerve (hearing) and the vestibular nerve (sense of space, balance) moves from the ear to the brain stem.

Regenerative Medicine Injections

Prolotherapy is an injection technique that stimulates repair of unstable, torn, or damaged ligaments. When the cervical ligaments are unstable, they allow for excessive movement of the vertebrae, which can then restrict blood flow to the brain, pinch on nerves (a pinched nerve causing Vestibular migraine and spontaneous vertigo), and cause other symptoms associated with joint instability, including cervical instability.

Treating cervical ligaments – published research from Caring Medical

In our 2014 research headed by Danielle R. Steilen-Matias, PA-C, We also noted that when the cervical ligaments are injured, they become stretched out and loose. This allows for excessive abnormal movement of the cervical vertebrae.

  • In the upper cervical spine (C0-C2), this can cause symptoms such as nerve irritation and vertebrobasilar insufficiency with associated vertigo, tinnitus, dizziness, facial pain, arm pain, and migraine headaches.

Treating and stabilizing the cervical ligaments can alleviate the problems of  Vestibular migraine and spontaneous vertigo by preventing excessive abnormal vertebrae movement, the development or advancing of cervical osteoarthritis, and the myriad of problematic symptoms they cause.

If this article has helped you understand the problems of cervical vertigo and you would like to explore Prolotherapy as a possible remedy, ask for help and information from our specialists

Continue with your research with these articles:

1 Hilton DB, Shermetaro C. Migraine-Associated Vertigo (Vestibular Migraine). InStatPearls [Internet] 2019 Jun 4. StatPearls Publishing. [Google Scholar]
2 King S, Priesol AJ, Davidi SE, Merfeld DM, Ehtemam F, Lewis RF. Self-motion perception is sensitized in vestibular migraine: pathophysiologic and clinical implications. Scientific reports. 2019 Oct 4;9(1):1-2. [Google Scholar]
3 Dornhoffer JR, Liu YF, Donaldson L, Rizk HG. Factors implicated in response to treatment/prognosis of vestibular migraine [published online ahead of print, 2020 May 24]. Eur Arch Otorhinolaryngol. 2020;10.1007/s00405-020-06061-0. doi:10.1007/s00405-020-06061-0 [Google Scholar]

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