Imagine waking up feeling like the room is spinning, your head pounding, and even the sound of your own breathing feels too loud. You’re not dizzy from standing up too fast. You’re not sick with the flu. You’ve had this before - and it’s not just a bad headache. This is vestibular migraine, and it’s more common than most people realize. In fact, it’s the leading cause of spontaneous dizziness seen in specialty clinics, affecting about 1 in 100 people, with women three and a half times more likely to experience it than men. Yet, most patients wait over a year before getting the right diagnosis. Why? Because it looks like other conditions - BPPV, Ménière’s disease, even anxiety. But it’s not. And treating it like those other things doesn’t work.
What Exactly Is Vestibular Migraine?
Vestibular migraine isn’t just a headache that makes you feel off-balance. It’s a neurological condition where the brain’s pain and balance systems get tangled up. You might get vertigo - that spinning, swaying, or floating feeling - without any head pain at all. Or you might have a classic migraine with throbbing pain, nausea, and light sensitivity, but the dizziness is the worst part. Episodes can last from five minutes to three days. Some people get warning signs, like flashing lights or tingling, before the dizziness hits. Others just wake up in the middle of the night feeling like they’re on a boat.
The key to diagnosis? Two things: a history of migraine (even if it’s mild or infrequent), and at least five episodes of moderate-to-severe dizziness lasting 5 minutes to 72 hours, with clear signs of migraine during the attack - like sensitivity to light or sound, or a headache that develops during the episode. There’s no blood test or scan that confirms it. Doctors have to rule everything else out. That’s why so many people get misdiagnosed. About 40% are told they have BPPV and get repositioning maneuvers that don’t help. Another 25% are treated as if they have Ménière’s disease, given diuretics that do nothing for their migraine.
What Triggers Your Attacks?
Knowing your triggers is the first step to taking control. In a survey of over 850 people with vestibular migraine, the top triggers were clear:
- Stress - reported by 82% of patients
- Sleep disruption - 76%
- Weather changes - 68%
- Caffeine - 54%
- Alcohol - 49%
- Aged cheeses, processed meats, MSG - 38%
One woman in Halifax told me she noticed every attack came after a long weekend of poor sleep and coffee. Another found that skipping meals triggered dizziness even if she didn’t get a headache. The pattern isn’t always obvious, but keeping a daily symptom diary for 6 to 8 weeks helps. Write down what you ate, how much you slept, your stress level, the weather, and when the dizziness hit. Over time, patterns emerge. You might find that your triggers aren’t just food - they’re combinations. Maybe it’s caffeine + lack of sleep + a cold front. Once you know, you can start avoiding the combo.
How to Stop an Attack When It Hits
When the room starts spinning, your goal is simple: reduce the noise, the light, and the motion. The Cleveland Clinic found that resting in a dark, quiet room reduces symptom severity by 35%. That’s not a small win. Drink 2 liters of water - dehydration makes dizziness worse. Avoid screens. Don’t try to push through.
For medication, the approach is split: treat the headache, treat the dizziness.
For headache pain, sumatriptan (50-100 mg) works for about 70% of people within two hours. If you can’t swallow pills during an attack, the nasal spray or injection versions are options. Ibuprofen or naproxen help about half the time, but they’re slower and less reliable than triptans.
For dizziness and nausea, the go-to drugs are prochlorperazine (5-10 mg) and ondansetron (4-8 mg). Prochlorperazine clears vertigo in nearly 7 out of 10 people within two hours. Ondansetron doesn’t stop the spinning, but it kills nausea so you can breathe. Benzodiazepines like lorazepam can help too, but they’re risky long-term - they can make your balance worse over time by slowing down your brain’s ability to adapt.
Don’t rely on these drugs daily. They’re for emergencies. Overusing them can make your brain more sensitive, leading to more frequent attacks.
Preventing Attacks Before They Start
If you’re having more than four attacks a month, prevention is not optional - it’s essential. Delaying treatment increases your risk of chronic dizziness by 30% within two years, according to experts at Mayo Clinic.
First-line preventive meds are proven and widely used:
- Propranolol (40-160 mg daily): Reduces attack frequency by 50% in 62% of patients.
- Amitriptyline (10-75 mg at night): Works for 40-60% of people. Side effects? Drowsiness - reported by 65% of users. But for many, it’s worth it.
- Topiramate (25-100 mg daily): 54% of patients cut their attacks in half. But brain fog and tingling are common complaints.
- Verapamil (120-240 mg daily): A calcium channel blocker that’s especially helpful if you have aura or light sensitivity.
- Flunarizine (5-10 mg daily): Not approved in the U.S., but widely used in Europe. Works in nearly half of patients.
Many people quit these meds because of side effects. That’s normal. Finding the right one often takes 2-3 tries. Don’t give up after the first one makes you tired. Talk to your doctor about adjusting the dose or switching.
For those who want to avoid pills, supplements have solid evidence:
- Magnesium (600 mg daily): Reduces attack frequency by 30-40% with almost no side effects.
- Riboflavin (B2) (400 mg daily): Shown in studies to cut attacks by up to 40%.
- Coenzyme Q10 (300 mg daily): Also cuts frequency by about 35%.
These take 2-3 months to work, but they’re gentle. Many patients use them alongside meds to reduce the dose needed.
Vestibular Rehabilitation Therapy - The Game Changer
Here’s the secret most people don’t know: your brain can retrain itself. Vestibular rehabilitation therapy (VRT) isn’t just for people who’ve had inner ear surgery. It’s for anyone whose brain has gotten confused by repeated dizziness.
VRT uses simple, guided exercises - like moving your head slowly while focusing on a fixed point, or standing on one foot with your eyes closed - to help your brain rely less on your inner ear and more on your vision and body sense. After 8-12 sessions, 78% of patients in one study reported more than 50% improvement. That’s not just feeling a little better. That’s going back to work, driving, walking the dog without fear.
The best part? You can do it at home after the first few sessions. Daily 10-minute routines make a huge difference. It’s not magic. It’s physical therapy for your balance system. And it’s strongly recommended by both the European and American neurological societies.
What Doesn’t Work - And Why
So many people waste months on treatments that don’t touch the root cause.
- Diuretics (like hydrochlorothiazide): These help Ménière’s disease, but only 20% of vestibular migraine patients respond. Giving them to someone with VM is like giving insulin to someone with a cold.
- Corticosteroids: These work for vestibular neuritis (a viral infection), but only 30% of VM patients improve. The inflammation in VM isn’t the same.
- Prolonged benzodiazepines: They stop dizziness short-term, but long-term use prevents your brain from relearning balance. It’s like putting a bandage on a broken leg and never setting the bone.
- Butterbur: It used to be popular - 45% reduction in attacks in one study. But since 2015, safety warnings about liver damage have made it a no-go. Skip it.
And yes, even some “natural” remedies sold online have no proof. Stick to the ones with real data: magnesium, riboflavin, coenzyme Q10, and VRT.
The Road to Recovery
Recovery isn’t about being perfect. It’s about managing. Most people need a mix of prevention, acute treatment, and rehab. One woman in her 40s, a teacher from Dartmouth, went from 12 attacks a month to 1-2 after six months of propranolol, magnesium, and daily VRT exercises. She still avoids caffeine and doesn’t skip meals. She doesn’t have a cure - but she has her life back.
Success means:
- Reducing attacks by 50% or more
- Being able to work, drive, and do daily tasks without fear
- Not needing to rely on emergency meds every week
It takes time. You’ll try something that doesn’t work. You’ll get frustrated. But you’re not alone. Over 1.2 million people in the U.S. have been diagnosed. And new treatments are coming fast. In 2023, the FDA approved atogepant, a new preventive that cut attacks by 56% in VM patients. Trials for rimegepant and non-invasive nerve stimulators show promise too.
The biggest mistake? Waiting. If you’ve had more than three dizziness episodes in a year, especially with migraine symptoms, see a neurologist who specializes in headaches. Don’t wait for your doctor to say, “It’s probably just stress.” It might be vestibular migraine. And it’s treatable.
Can vestibular migraine happen without a headache?
Yes. In fact, about half of all vestibular migraine attacks occur without any head pain. The key signs are dizziness, imbalance, nausea, and sensitivity to light or sound during the episode, especially if you have a personal or family history of migraine. The diagnosis relies on the pattern of symptoms, not the presence of a headache.
How long does vestibular rehabilitation therapy take to work?
Most people start noticing improvement after 4-6 weeks of consistent daily exercises. A full course usually takes 8-12 supervised sessions, followed by home exercises for 3-6 months. Studies show 40-60% improvement in dizziness handicap scores after completing the program. The key is consistency - doing the exercises even on days you feel okay.
Are there any new treatments on the horizon?
Yes. In 2023, the FDA approved atogepant, a CGRP inhibitor, for migraine prevention - and early data shows it works well for vestibular migraine too. Rimegepant, another CGRP drug, reduced vertigo days by nearly 50% in a 2022 trial. Non-invasive vagus nerve stimulators (like gammaCore) also show promise, cutting vertigo frequency by 45% in early studies. Researchers are also testing vestibular-evoked myogenic potentials (VEMPs) as a diagnostic tool, which could cut diagnosis time from over a year to weeks.
Why do I feel dizzy even when I’m not having an attack?
Repeated attacks can make your brain overly sensitive to motion and balance signals - a process called central sensitization. This means even normal movements, like turning your head quickly or walking in a crowded store, can trigger dizziness. That’s why vestibular rehabilitation is so important: it retrains your brain to ignore false signals and rely on your body’s natural balance system again.
Can stress really cause vestibular migraine attacks?
Absolutely. Stress is the #1 trigger, reported by 82% of patients. It doesn’t have to be major trauma - even mild, ongoing stress like work pressure, lack of sleep, or emotional overload can lower your brain’s threshold for an attack. Managing stress through mindfulness, regular sleep, and pacing your day can be as effective as medication for many people.
What to Do Next
Start with a symptom diary for 6 weeks. Track your dizziness, headaches, sleep, food, and stress. Then, see a neurologist who treats migraines - not just any doctor. Ask if they’ve treated vestibular migraine before. If not, ask for a referral to a headache clinic. Bring your diary. Don’t accept a diagnosis of “just stress” or “BPPV” without ruling out VM.
If you’ve been diagnosed, don’t stop at one medication. Try supplements. Start vestibular rehab. Cut caffeine. Get enough sleep. You don’t need to fix everything at once. Pick one thing - maybe magnesium or daily walking - and build from there. Progress isn’t linear. But with the right approach, most people go from disabled to living well.
