Diagnostic challenges in vestibular migraine—clinical differentiation from Menière’s disease and discrepancies with current classification criteria

Background Vestibular migraine (VM) and Menière’s disease (MD) are spontaneous episodic vestibular syndromes and often present with overlapping features, making clinical differentiation challenging. This study aimed to (1) identify key features distinguishing VM from MD and (2) investigate discrepancies between expert diagnosis and International Classification of Vestibular Disorders (ICVD) criteria for VM. Methods We analyzed data from patients diagnosed with VM or MD at the tertiary dizziness center of LMU Munich. Diagnostic classification was based on ICVD criteria and expert judgment. Symptoms, vestibulo-ocular reflex (VOR) function, and demographics were compared. A conditional inference tree identified key differentiators. For ‘suspected VM’ cases not meeting ICVD criteria, reasons for diagnostic discrepancy were analyzed. Results We included 290 patients: 188 with VM and 88 with MD. VM was more common in women (72% vs. 51%) and had an earlier onset (39.6 vs. 49.9 years). MD patients had more rotational vertigo, greater caloric asymmetry, and lower VOR gains on video head impulse testing (all p < 0.0001). The tree identified seven key variables and achieved 86% accuracy. Sixty-six VM patients were diagnosed as ‘suspected VM’ based on expert judgment. Discrepancies were primarily due to short attack duration and atypical symptoms. Conclusions This study identified seven clinical variables to effectively distinguish VM from MD. While VM and MD share overlapping features, diagnostic ambiguity remains common, particularly in cases not meeting ICVD criteria. Our findings support the introduction of a ‘suspected VM’ category to capture patients with atypical presentations not covered by ICVD criteria.