Clinical heterogeneity in acute vestibular migraine attacks

Background: In patients with vestibular migraine (VM), from a clinical standpoint, it is not uncommon for patients to lack the complete criteria of VM. The study aimed to identify possible signs of VM and suggest a protocol for diagnosing patients who may not meet all the usual criteria. Materials and Methods: During the period from March 2019 to February 2024, 57 patients with VM out of 265 dizzy patients (21.5%) were retrospectively selected and reviewed. All patients underwent full history taking, basic audiologic evaluation, office vestibular examination, videonystagmography (VNG), and brain magnetic resonance imaging with contrast. Migraine prophylactic drugs (topiramate or amitriptyline) were prescribed, and the dosages were modified based on the patient’s therapeutic response. Results: Three categories of patients were identified: definite migraine (25 patients, 43.9%), probable migraine (10 patients, 17.5%), and investigational nonmigraine recurrent headache (22 patients, 38.6%). The VNG test outcomes of all 57 patients showed positioning and/or positional nystagmus (PN) with mixed peripheral and central characteristics. Other VNG test results for all patients were normal (spontaneous nystagmus, oculomotor tests, and caloric test). Migraine preventive medicines significantly reduced headache and dizziness episodes in the three studied groups. Conclusion: VM is not merely a disease but a spectrum of wide clinical presentations. VM patients presented with PN exhibiting mixed peripheral and central characters. It is suggested that future studies look at the potential of expanding the current diagnostic criteria to encompass atypical migraine.