Dizziness: When Is It Migraine, and When Is It Not?

Abstract

Purpose of review: Dizziness is a frequent neurologic symptom in patients with headache, which overlaps with many etiologies beyond vestibular migraine. This review aims to help neurologists distinguish when dizziness is due to vestibular migraine (VM) versus other vestibular syndromes.

Recent findings: VM is now recognized as the most common cause of spontaneous episodic vertigo, with expanding diagnostic criteria, new pathophysiological insights involving CGRP, and emerging treatment strategies including anti-CGRP therapies. It overlaps with benign paroxysmal positional vertigo (BPPV), Meniere's disease, persistent postural-perceptual dizziness (PPPD), and cerebrovascular events. Novel tools such as the Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI) and frameworks like Timing, Triggers And Targeted Examination (TiTrATE) enhance diagnostic accuracy and patient outcomes. Differentiating VM from other causes of dizziness relies on a detailed clinical history, neurological examination, and increasingly, awareness of VM's protean features and comorbidities. Recognition is essential as treatments can differ significantly across etiologies. Future research should target biomarkers, subtypes and comparative treatment trials for VM and its mimics.

Keywords: Benign paroxysmal positional vertigo; Mal de débarquement syndrome; Meniere’s disease; Motion sickness; Persistent postural-perceptual dizziness; Vestibular migraine; Vestibular neuritis.