By Dara G. Jamieson, MD
Synopsis: Two distinct vestibular disorders, persistent postural-perceptual dizziness (PPPD) and vestibular migraine (VM), both involve vertigo as a primary symptom. Nearly half of chronic migraine patients also experience vertigo, especially those with aura and allodynia. Since PPPD is seen as a functional maladaptation and VM is associated with cortical hyperexcitability, treatment for vertigo in these two conditions should be tailored to their unique pathophysiological mechanisms.
Sources: Karsan N, Vandenbussche N, Jenia-Wilcha R, et al. Evaluating associations of migraine-related vertigo. Headache. 2025; Oct 26. doi: 10.1111/head.15038. [Online ahead of print].
Moreno-Ajona D. Persistent postural-perceptual dizziness versus vestibular migraine: A narrative review. Headache. 2025; Oct 28. doi: 10.1111/head.15078. [Online ahead of print].
The review by Moreno-Ajona explores persistent postural-perceptual dizziness (PPPD) and vestibular migraine (VM), which are common vestibular disorders with overlapping, female-predominant demographics and symptoms of dizziness, vertigo, unsteadiness, and visual sensitivity. However, they have distinct temporal profiles, pathophysiological mechanisms, and treatments. Moreno-Ajona wrote that VM may reflect a disorder of organic cortical hyperexcitability and PPPD is considered a chronic, functional, maladaptation disorder.
Whereas PPPD is the most common cause of persistent dizziness with symptoms lasting three or more months, VM is the leading cause of episodic vertigo and is associated with migraine features, such as headache, photophobia, phonophobia, and visual aura. This distinction between these causes of chronic and episodic dizziness may be less apparent in patients with chronic VM, since migraine is a frequent trigger for PPPD.
The migraine pathophysiology of VM includes cortical hyperexcitability and trigeminovascular system dysregulation, with calcitonin gene-related peptide (CGRP) playing a central role. Hyperactive visual and vestibular cortical areas and altered thalamocortical networks are correlated with VM. The persistent dizziness of PPPD is caused by maladaptive changes in postural control and multisensory integration, which may be associated with multiple triggers, such as upright posture, motion, complex visual stimuli, vestibular events, or psychological stressors. Neuroimaging in PPPD shows altered connectivity in visuo-vestibular and anxiety networks, with heightened visual dependence and reduced vestibular cortical activity.
Although both disorders involve altered visuospatial perception and multisensory integration, the differences between PPPD and VM indicate the diagnosis and treatment. Vestibular rehabilitation therapy (VRT), cognitive behavioral therapy (CBT), and serotonergic medications for anxiety and symptom management are used to treat PPPD. The usual migraine preventive medications are used to treat VM, but the options for effective, specific treatment for an acute attack of VM are limited.
In their paper, Karsan et al reported their investigation of the prevalence and predictors of vertigo in patients with chronic migraine. The associations between vertigo and other migraine-related symptoms were explored retrospectively using data from the clinic letters from patients seen at the King’s College Hospital Tertiary Headache Service between January 2015 and December 2021. Out of 589 patients with chronic migraine without a formal diagnosis of VM, 275 patients complained of vertigo. With the patients with chronic migraine, 51.1% reported aura and 64.6% reported allodynia. The patient age range, female predominance, and headache frequency were similar in the groups with and without vertigo. Patients with aura had 2.13 times higher odds of reporting vertigo, while those with allodynia had 2.74 times higher odds. Other sensory sensitivities, such as photophobia, phonophobia, and osmophobia, were not significantly associated with vertigo, although another published study found an association of vertigo with osmophobia in children. Patients with chronic migraine and vertigo were more likely to report premonitory symptoms (i.e., concentration difficulty, mood change, neck discomfort) prior to their headaches and to have cranial autonomic symptoms (i.e., facial changes, lacrimation, nasal congestion), with a reporting rate of 88.1% and 76.4%, respectively.
The authors suggested that vertigo may indicate a more enriched migraine phenotype, independent of headache frequency, and that targeting associated migraine symptoms, such as vertigo, could improve treatment outcomes. Prospective studies with standardized data collection, which also account for the detailed characteristics of vertigo and accompanying comorbid conditions, are needed to better characterize vertigo in patients with migraine and to develop targeted treatment strategies for this disabling symptom.
Commentary
Patients with migraines may be disabled by their accompanying symptoms even more than from the acute head pain itself. Prescribed treatments for migraine often focus on alleviating pain, without accounting for the treatment response to those migraine-associated symptoms that have a significant functional effect. Vertigo is a common symptom associated with chronic migraine that causes profound and prolonged disability and it appears particularly resistant to the usual migraine acute and preventive treatments.
Karsan et al found that vertigo was associated with a more enriched migraine but, out of all the sensory sensitivities associated with migraine, only allodynia had an association with vertigo. The study did not account for psychiatric disorders, such as depression and anxiety, which could be relevant confounders in the identification of vertigo. Additionally, variables such as disease duration and headache severity were not accounted for in their analysis. As Karsan et al suggested, prospective studies with standardized data collection, accounting for detailed characteristics of vertigo and for the patients’ comorbid conditions, are needed to better characterize vertigo in migraine.
The review by Moreno-Ajona highlights the importance of a precise and accurate diagnosis and of the implementation of tailored treatment strategies to optimize patient outcomes and improve quality of life for individuals with PPPD and VM, individually or in combination. However, the review points out the overlap between these conditions, since vertigo may become chronic in patients with migraine.
Studies of migraine-accompanying symptoms, including vertigo, tell us how to decrease overall migraine disability. Early treatment with effective acute abortive medications prevents the development of allodynia, with a concomitant decrease in migraine-associated vertigo. Aggressive lifestyle and medication regimens to decrease the frequency and severity of migraine attacks will decrease aura frequency, with a concomitant decrease in migraine-associated vertigo. Given the interplay between chronic VM and PPPD, the suggestion that VRT, cognitive CBT, and serotonergic medications for anxiety be tried for the treatment of PPPD should be extended to patients for whom vertigo is a debilitating chronic migraine-accompanying symptom. Treatment of migraine in patients with prominent accompanying symptoms, including vertigo, should be expanded beyond the isolated migraine pain paradigm.
Dara G. Jamieson, MD, is Clinical Associate Professor of Neurology, Weill Cornell Medical College.
