Vestibular Migraine: Dizziness Without the Headache

The room tilts for forty minutes, twice a month, and there is no headache at all. So it does not get mentioned to anyone as a migraine problem, and it usually gets investigated as an ear problem first.

Vestibular migraine is defined in a way that makes the absence of headache unremarkable rather than disqualifying, and the definition is public. What it asks for is a count and a duration, which means the thing standing between most people and a useful appointment is a record rather than an insight.

The criteria, as three things to record

The criteria were written jointly by the Bárány Society and the International Headache Society, and appear in the appendix of the headache classification as A1.6.6 vestibular migraine. Three components:

At least five episodes of moderate or severe vestibular symptoms, lasting between five minutes and 72 hours.

A current or past history of migraine, with or without aura.

One or more migraine features during at least 50% of the episodes — a headache with at least two of the usual characteristics (one-sided, pulsating, moderate or severe, worse with routine activity), or photophobia and phonophobia together, or visual aura.

Read the third one carefully, because it is the part that surprises people. The features have to be present in at least half of the episodes, not in all of them. Half your episodes can be pure dizziness with nothing else attached and the pattern still fits. That is why “but I don’t get a headache with them” is not the conversation-ender it feels like.

Note also that this sits in the appendix of the classification rather than the main body, which is a signal about how settled the entity is rather than about whether people have it.

The three things people cannot answer when asked

Every part of the above is a question a clinician will put to you, and each has a predictable failure.

How many episodes have you had? “Loads” and “a few times a month for years” are the usual answers, and neither reaches five in a countable form. The threshold is low and specific, and hitting it on paper takes a few months of marks.

How long do they last? This is the one people get most wrong, because a five-minute-to-72-hour range spans three orders of magnitude and dizziness distorts time badly. Episodes are routinely remembered as “about an hour” when the record shows twelve minutes, and the direction of the error is not consistent. Anything under five minutes falls outside the definition entirely, which makes the difference between a guessed and a timed duration decision-relevant.

Were there migraine features? Answered in aggregate — “sometimes I get light sensitivity” — when the criteria want a proportion. Half is the number, and half is unknowable without per-episode marks.

What to write down

Four fields, once per episode.

• Date and start time
• How long the dizziness lasted, in minutes, noted when it stops rather than estimated later
• Moderate or severe, two bands, matching the wording of the criteria
• Which features were present: headache and roughly what kind, light and sound sensitivity together, visual aura, or none

That last field is the one that determines whether you can answer the 50% question, and it needs the “none” marked as deliberately as the rest. An episode log that only records the interesting episodes cannot produce a proportion.

A fifth field is worth adding for anyone whose episodes are hard to categorise: what the dizziness actually was. Spinning, a sense of being pushed or tilted, unsteadiness while walking, or visually provoked — brought on by scrolling, supermarket aisles, traffic. Those distinctions matter to the people who investigate this and are exactly what memory blurs first.

Why the record does the heavy lifting here

More than in most headache conditions, this one is a counting problem.

The differential includes several other things that cause episodic vertigo, and they are separated substantially by duration and by what accompanies them rather than by how the dizziness feels. A pattern of episodes with times attached is genuinely diagnostic material in a way that a description of the sensation is not, and it is the material almost nobody arrives with.

There is also a practical point about who you end up in front of. Isolated dizziness usually routes to an ear, nose and throat clinic or an audiology service, sometimes for years, while the migraine history sits unmentioned in a different part of the notes. A page showing five timed episodes, three of them with photophobia and phonophobia, alongside a history of migraine in your twenties, is the thing that gets the two halves of your record into the same room. Referrals run on facts of that kind, and doubt over a diagnosis is one of the standard reasons a GP can act on.

Two months, then the appointment

Five episodes is the threshold, so the tracking period is however long five takes.

Mark them as they end, not that evening. Duration is the field that decays fastest, and it is the one carrying the most weight here. The free printable diary has a row per day and a notes column wide enough for the four fields, and Migraine Journal timestamps entries as you make them, which is what preserves the start time and the order of events when a memory of the afternoon will not.

Take the count and the durations to the appointment on one page, in the same format as any other headache record — what to bring to a neurologist appointment covers the layout, and the migraine history section matters more here than usual, including attacks you had decades ago and stopped having.

Nothing here is a diagnosis and none of it should be used as one. Vertigo has causes that are neither benign nor migraine, and dizziness arriving with new neurological symptoms, hearing loss, or a sudden severe headache is a reason to be seen now rather than recorded. The other tracking guides work from the same per-episode record.