Vestibular Migraine: How to Manage Dizziness and Headache Episodes

If you’ve ever felt like the room is spinning even when you’re sitting still - and then got a pounding headache right after - you might be dealing with vestibular migraine. It’s not just a bad headache. It’s a neurological condition that mixes vertigo, dizziness, and migraine in ways that can wreck your daily life. Unlike typical migraines, you don’t always get the head pain. Sometimes, it’s just the spinning, the nausea, the light sensitivity - and no one seems to understand why.

It’s more common than you think. About 1 in 100 people have it. Women are 3.5 times more likely to be affected than men. And here’s the kicker: most people wait over a year to get diagnosed. Too many end up being told they have BPPV (a simple inner ear issue) or Ménière’s disease - and get treatments that don’t touch the real problem. That’s because vestibular migraine doesn’t show up on scans or blood tests. It’s diagnosed by your history, your symptoms, and how they line up with migraine patterns.

What Exactly Is Vestibular Migraine?

Vestibular migraine is when your brain’s balance system gets caught in the same storm as your pain pathways. The same nerve networks that trigger migraine headaches also mess with your inner ear signals. That’s why you get dizzy, unsteady, or feel like you’re on a boat even when you’re standing still.

Episodes can last anywhere from 5 minutes to 3 days. Some people get them once a month. Others have them weekly. The vertigo isn’t always violent - sometimes it’s just a vague sense of imbalance, or a feeling that things are moving when they’re not. Alongside that, you might notice:

• Sensitivity to light (photophobia)
• Sensitivity to noise (phonophobia)
• Blurred vision or visual aura (zigzag lines, blind spots)
• Nausea or vomiting
• Feeling worse with movement - like walking, turning your head, or riding in a car

And here’s the thing: you might not even have a headache during an attack. That’s why so many people are misdiagnosed. If you’ve had migraine headaches in the past - even if they’re rare now - and you’re suddenly getting dizziness, vestibular migraine is likely the culprit.

What Triggers These Attacks?

Triggers vary from person to person, but a few show up over and over again in patient logs and clinical studies:

• Stress - 82% of people report it as a major trigger
• Sleep disruption - too little, too much, or irregular sleep patterns
• Weather changes - barometric pressure shifts, humidity, or storms
• Caffeine - both too much and sudden withdrawal
• Alcohol - especially red wine
• Aged cheeses - cheddar, blue, brie - anything with tyramine
• Hormonal shifts - common in women around menstruation or menopause

Keeping a symptom diary for 6-8 weeks is the single most useful thing you can do. Write down what you ate, how much you slept, your stress level, and exactly what happened during each episode. You’ll start seeing patterns. Maybe it’s not coffee - maybe it’s coffee after a bad night’s sleep. That’s the kind of insight that changes everything.

How Is It Diagnosed?

No MRI will confirm vestibular migraine. No blood test will show it. Diagnosis is based on strict criteria from the International Headache Society:

1. You’ve had at least 5 moderate-to-severe episodes of vertigo or dizziness
2. Each episode lasts 5 minutes to 72 hours
3. You have a history of migraine (with or without aura)
4. During at least half of the episodes, you also have one or more migraine features - headache, light/sound sensitivity, or visual aura
5. No other cause (like inner ear disease or neurological disorder) explains the symptoms

Doctors will often rule out other conditions first. That’s why you might see an ENT, then a neurologist, then a vestibular therapist. It takes time. But if your symptoms match this pattern - especially if you’ve had migraines before - it’s likely vestibular migraine.

How to Treat It: The Three-Step Plan

Treatment isn’t one-size-fits-all. But most successful cases follow a clear three-step approach:

Step 1: Lifestyle and Trigger Management

This is where most people start - and where many fail because they skip it. You can’t medicate your way out of triggers. You have to manage them.

• Cut back on caffeine - not just coffee, but energy drinks, chocolate, and even some painkillers that contain caffeine
• Keep sleep regular - same bedtime, same wake time, even on weekends
• Stay hydrated - 2 liters of water a day, especially during attacks
• Avoid known food triggers - aged cheeses, processed meats, MSG, artificial sweeteners
• Manage stress - even 10 minutes of daily breathing exercises can cut attack frequency by 20%

One study found that simply stopping caffeine reduced attacks by 35%. That’s more than some medications.

Step 2: Managing Acute Attacks

When an attack hits, you need fast relief - for both the dizziness and the headache.

For dizziness and nausea:

• Prochlorperazine - 5-10 mg orally. Works in under 2 hours for 68% of people
• Ondansetron - 4-8 mg. Great for nausea, no drowsiness
• Domperidone - 10-20 mg. Effective for nausea, low risk of side effects

For headache:

• Sumatriptan - 50-100 mg. Works for 70% of headache pain within 2 hours
• Ibuprofen or naproxen - 400-800 mg. Good for mild to moderate pain

Also, don’t underestimate the power of the dark room. Lying down in silence, with no screens, no noise, and no movement - this reduces symptom severity by 35% on average. It’s not a cure, but it gives your brain a chance to reset.

Step 3: Preventing Future Attacks

If you have more than 4 attacks a month, prevention is key. And there are several proven options:

• Propranolol - 40-160 mg daily. Works for 62% of patients in reducing attack frequency
• Metoprolol - 50-200 mg daily. Similar effectiveness, fewer side effects for some
• Amitriptyline - 10-75 mg at night. Reduces vertigo frequency by 40-60%. Side effects: drowsiness, dry mouth
• Topiramate - 25-100 mg daily. 54% of patients cut attacks in half. Side effects: brain fog, tingling
• Verapamil - 120-240 mg daily. A calcium channel blocker that works well for those who can’t tolerate beta-blockers
• Flunarizine - 5-10 mg daily. First-line in Europe. Not FDA-approved in the U.S., but widely used off-label

Non-drug options also work:

• Magnesium - 600 mg daily. Reduces attack frequency by 30-40%
• Riboflavin (B2) - 400 mg daily. Proven in clinical trials
• Coenzyme Q10 - 300 mg daily. Minimal side effects, good for long-term use

Many people try one or two of these before finding what works. Don’t give up after the first try. It often takes 2-3 tries to find the right fit.

Vestibular Rehabilitation Therapy (VRT): The Game-Changer

This is the part most people overlook - and it’s one of the most effective.

Vestibular rehabilitation therapy (VRT) is a set of customized exercises designed to retrain your brain to rely less on your inner ear and more on your vision and body senses for balance. It’s not about fixing your inner ear. It’s about rewiring how your brain interprets signals.

Studies show:

• 45-60% improvement in dizziness severity after 8-12 weeks
• 78% of patients report over 50% symptom reduction after 12 sessions
• Benefits last long after therapy ends

VRT isn’t just for people with chronic dizziness. Even if you’re still getting attacks, VRT helps you recover faster and feel more stable between episodes. It’s strongly recommended by the European Academy of Neurology and supported by multiple randomized trials.

Most clinics offer 6-10 sessions with a physical therapist trained in vestibular disorders. Then you do daily home exercises - 10-15 minutes a day. It’s not glamorous. But it works.

What Doesn’t Work - And Why

So many people waste time on treatments that don’t touch vestibular migraine:

• Diuretics (like hydrochlorothiazide) - used for Ménière’s disease. Only 20% of VM patients respond. They won’t help you.
• Corticosteroids - used for vestibular neuritis. Only 30% effective for VM. You’re treating the wrong thing.
• Prolonged benzodiazepines (like Valium or Xanax) - they might calm you down short-term, but they interfere with your brain’s natural ability to adapt. Long-term use can make dizziness worse.
• Butterbur - once popular. But it can damage your liver. Withdrawn in Europe and warned against in the U.S. since 2015.

And here’s the big one: misdiagnosis. Over 40% of vestibular migraine cases are mistaken for BPPV or Ménière’s. If you’ve had canalith repositioning maneuvers (like the Epley maneuver) and it didn’t help - that’s a red flag. BPPV is short, sharp spins triggered by head movement. Vestibular migraine is longer, more variable, and tied to migraine triggers.

What’s New in 2025-2026

The field is moving fast. In 2023, the FDA approved atogepant for migraine prevention - and early data shows 56% of vestibular migraine patients had fewer attacks. Rimegepant, another new drug, reduced vertigo days by 49% in a 2022 trial. These are part of a new class called CGRP inhibitors - originally designed for headaches, but they’re working for dizziness too.

Genetic testing is starting to play a role. If you have a mutation in the CACNA1A gene (found in about 25% of families with VM), you’re more likely to respond to calcium channel blockers like verapamil. It’s not routine yet - but it’s coming.

Non-invasive devices like gammaCore (a vagus nerve stimulator) are now FDA-cleared for migraine prevention. In trials, it cut vertigo frequency by 45%. It’s a small handheld device you use for 2 minutes a day. No pills. No side effects.

And researchers are close to a diagnostic test. A simple hearing and balance test called VEMPs (vestibular-evoked myogenic potentials) showed 82% accuracy in spotting vestibular migraine in 2022. If this gets rolled out widely, diagnosis could drop from 11 months to under 2 weeks.

What to Do Next

If you think this sounds like you:

1. Start a symptom diary - track food, sleep, stress, and dizziness for 6 weeks
2. See a neurologist who specializes in headaches - not just any neurologist
3. Ask about vestibular rehabilitation therapy - insist on it
4. Don’t accept a diagnosis of BPPV if it doesn’t fit your full pattern
5. Try one preventive supplement first: magnesium 600 mg daily, riboflavin 400 mg, or CoQ10 300 mg
6. If attacks are frequent, ask about propranolol or amitriptyline - both are generic, affordable, and well-studied

There’s no magic cure. But with the right approach - trigger control, targeted meds, and vestibular rehab - most people cut their attacks by 70% or more within 6 months. It takes patience. But it’s possible.