Rethinking Vestibular Migraine in Clinical Practice

Published in Current Opinion in Neurology (February 2026), Villar-Martinez and colleagues provide an overview of vestibular migraine (VM), emphasizing its diagnostic complexity, evolving phenotypic characterization, and emerging treatment strategies. VM is a neuro-otological condition involving vertigo and disturbances in spatial perception in individuals with a history of migraine. Its clinical heterogeneity and overlap with other vestibular disorders pose diagnostic challenges for clinicians.

A central theme of the review is the importance of detailed clinical phenotyping. Beyond established diagnostic criteria, features such as movement sensitivity, photophobia, cutaneous allodynia, and cognitive symptoms (e.g., “brain fog” and executive slowing) can improve diagnostic accuracy and help distinguish VM from mimicking conditions. The review further highlights the increasing recognition of cognitive and sleep-related disturbances in VM, with patients often demonstrating interictal cognitive deficits and impaired learning. Chronobiological factors, including hormonal influences (e.g., menstrual cycle and menopause) and longitudinal symptom evolution, are also emphasized as important components of patient assessment. The authors note that no single diagnostic test is definitive; rather, careful history-taking and bedside examination remain foundational.

Differential diagnosis is particularly challenging due to substantial overlap with other vestibular disorders such as benign paroxysmal positional vertigo (BPPV), Ménière’s disease (MD), and persistent postural-perceptual dizziness (PPPD). Notably, comorbid PPPD is common, and bidirectional relationships between these conditions suggest shared underlying mechanisms. Clinical clues such as motion sickness susceptibility and symptom patterns may aid differentiation, although overlap remains considerable. The review also highlights associations with dysautonomia, postural orthostatic tachycardia syndrome (POTS), and autoimmune conditions, suggesting that VM may lie within a broader neuro-immuno-autonomic spectrum.

Advances in neuroimaging provide further insight into VM pathophysiology. Structural and functional imaging studies point toward disrupted integration across vestibular, visual, and sensorimotor networks rather than focal lesions. Altered connectivity, abnormal cortical activity patterns, and dynamic instability in brain networks involved in spatial orientation and sensory processing have been consistently observed. Importantly, imaging findings may also assist in distinguishing VM from MD, as structural inner ear abnormalities such as endolymphatic hydrops are typically absent in VM.

Emerging evidence supports the use of calcitonin gene-related peptide (CGRP) monoclonal antibodies, with randomized controlled trials demonstrating reductions in dizziness burden. Onabotulinumtoxin-A has also shown benefit in early studies for reducing VM symptoms. However, heterogeneity in study design and the lack of vestibular-specific endpoints limit comparability across trials.

Ultimately, accurate diagnosis for VM hinges on detailed clinical anamnesis, careful eye-movement examination, and appropriate clinical context. While advances in neuroimaging and therapeutics are encouraging, further research is needed to develop multimodal evaluation strategies and phenotype-guided treatment approaches.

Reference:
Villar-Martinez MD, Abdalla A, Goadsby PJ. Vestibular migraine. Clinical and diagnostic challenges, and emerging therapeutic approaches. Curr Opin Neurol. 2026;39(1):42-47. doi:10.1097/WCO.0000000000001447