The 4 Stages of Vestibular Migraine Attacks Explained
According to the Vestibular Disorders Association (VEDA), migraine remains the 2nd leading cause of disability in the world, just behind low back pain. Migraine is a complex neurological disorder that can come with headache, light and sound sensitivity, and also dizziness or vertigo. Unlike many other disorders, migraine tends to impact people most during their most productive years, ages 20-40, resulting in massive economic losses. Despite it’s scale, migraine remains under recognized by healthcare professionals and lay people alike, with over 50% of migraine cases going undiagnosed. For those who do get an accurate diagnosis, it takes an average of 7 years for people to receive a migraine diagnosis.
Not everyone with migraine presents with dizziness but it’s estimated that approximately 55% of the migraine population will. Migraine variants that come with vertigo or dizziness is known as vestibular migraine.
What is Vestibular Migraine and How is it Different?
Vestibular migraine is the most common neurological cause of dizziness and vertigo. Largely thought to be genetic, people often have a family history of migraine. Vestibular migraine is characterized by spontaneous or triggered episodes of dizziness that last anywhere from 5 minutes to 72 hours. Interestingly enough, it is actually possible to have vestibular migraine without headaches.
There is wide range of presentations but symptoms can also include neck pain, speech difficulties, brain fog, visual disturbances, and more. Many people think migraine is isolated to the head and neck but migraine is actually a whole body disorder that can even include changes in urinary urgency or stomach upset.
Our understanding of vestibular migraine has shifted drastically over the past decade. Old biological mechanisms of migraine were thought to be vascular in nature. Now, vestibular migraine is thought to result from dysregulated brain excitability that occurs in four distinct phases. Unfortunately, there is currently no cure for vestibular migraine although proper treatment can lead to a better quality of life or even remission.
The 4 Stages of Vestibular Migraine Attacks
Not everyone presents with a phased progression but phase models remain useful for understanding migraine pathology. Knowing the mechanism behind vestibular migraine and a concept known as “threshold theory” are essential to overcoming symptoms. The four phases are as follows.
1. Prodrome
These are the signs and symptoms that indicate a migraine attack is coming. Lasting hours to days, people often report symptoms such as lethargy or irritability. Other less well known signs include increased urinary frequency, yawning, and cravings.
2. Aura
Auras refer to sensory disturbances right before an attack. Symptoms of aura are much more distinguishable than those of prodrome.
Visual disturbances are most common. But auras can also include numbness or tingling, speech difficulties, or even weakness in rarer presentations.
3. Attack
Symptoms are at their worst during the actual attack. Typically lasting from hours to even days. Symptoms can include light & sound sensitivity, headache, ear fullness, and of course vertigo.
The aforementioned symptoms are not an all inclusive list given the spectrum of vestibular migraine presentations.
4. Postdrome
Aptly named the “migraine hangover”, postdrome refers to symptoms following the peak of a migraine attack. Symptoms are often residual and can include tiredness, motion sickness, nausea, or brain fog.
The Interictal State Between Attacks
The interictal state refers to the time period between acute migraine attacks.
While many people may be asymptomatic during the interictal phase, it isn’t uncommon for people to present with more chronic symptoms as well.
The interictal state might not technically be a “phase” of an acute attack, but it is by all means an important concept to understand. It affirms that migraine is a complex neurological disorder, not just episodic headaches or vertigo.
Threshold Theory
Before diving into action steps, it’s important to define the concept known as “threshold theory”.
People living with migraine essentially have brains that are hypersensitive to sensory stimuli. Examples can include bright lights, loud noises, stress, or even weather changes. Each of these triggers however in isolation aren’t enough to cause an attack. Rather, it is the combination of cumulative triggers that lead to an attack once a critical “threshold” is reached.
Therefore, effective treatment doesn’t come from avoiding triggers altogether, but rather from raising your threshold. A higher threshold ensures a more resilient system leading to a better quality of life.
What To Do About It
There are many ways to raise your threshold if you’re suffering from vestibular migraine. Start by focusing on the basics such as sleep, regular exercise, and stress management. This builds a solid foundation for medical intervention.
People living with vestibular migraine should definitely have a neurologist on their team. Or better yet, a neuro-otologist, that is a physician who specializes at the intersection of the inner ear and brain. For certain cases, they may recommend medication to keep migraine attacks under control.
The final piece is vestibular rehabilitation, a specialized form of physical therapy for dizziness and vertigo. Vestibular therapy is unknown to many but it is actually very well established in medical literature.
Vestibular migraine is its own beast as compared to other vestibular disorders. It often involves a more comprehensive look at multiple physiological systems rather than just the ear. Suffice it to say regular exercise and vestibular rehab are some of the best tools we have to treat vestibular migraine.
If you’re having difficulty getting a handle on your migraine attacks, you’re not alone.
Dizziness often requires a more individualized approach. A personalized plan can help clarify what’s contributing to your symptoms and outline next steps. Get your FREE treatment plan from Pang PT here.