Vestibular migraine is the most common cause of spontaneously occurring, episodic vertigo; many patients whose dizziness is of uncertain origin turn out to have vestibular migraine¹.  The vast majority of patients experience both typical and vestibular migraine.  
Vestibular migraine can occur at any age, but the average age of onset of dizziness in migraine is about 40,  In older patients, particularly post-menopausal women, typical migraine attacks are sometimes replaced by isolated episodes of vertigo, dizziness or transient feelings of imbalance.

In children, benign paroxysmal vertigo, which has a strong association with a family history of migraine, is held to be the commonest cause of vertigo. 

The duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours, and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.

Vestibular migraine attacks, which are presumably often central in localization, may mimic acute unilateral vestibulopathy because there may be symptoms of spinning vertigo and signs of horizontal-torsional nystagmus.
Most vestibular migraine attacks abate within 24 to 72 hours after onset, unlike most cases of acute unilateral vestibulopathy.

Common features:

• Patients complain of light sensitivity, a heightened sense of the environment and both photo- and phonophobia. A minority of patients describe a typical vestibular aura.
• A history of profound motion sensitivity makes vestibular migraine more likely².
• The majority of patients have associated migraine headache, and diagnosis may be difficult in those without headache³. In the absence of headache, other migraine features such as photophobia or auras may have to be specifically inquired about⁴.
• Auditory symptoms, including hearing loss, tinnitus, and aural pressure have been reported in up to 40% patients with vestibular migraine¹. Hearing loss is usually mild and transient, with either no, or with only minor, progression in the course of the disease.
• Both horizontal and vertical positional nystagmus can be observed in vestibular migraine. In contrast to BPPV, the positional nystagmus of vestibular migraine is persistent and remains as long as the head remains in the provocative position (see video).  When the nystagmus is horizontal, both geotropic and apogeotropic positional nystagmus can be observed².
• Vestibular symptoms, as defined by the Bárány Society’s Classification of Vestibular Symptoms and qualifying for a diagnosis of Vestibular migraine, include:                                                                                                                                                                                                            

Diagnostic Criteria⁶

 A. At least five episodes fulfilling criteria C and D.  

 B. A current or past history of migraine without aura or with aura.

 C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours.

 D. At least 50% of episodes are associated with at least one of the following three migrainous features:

      1. Headache with at least two of the following four characteristics:

           a) Unilateral location;

          b) Pulsating quality;

          c) Moderate or severe intensity;

         d) Aggravation by routine physical activity.         

      2. Photophobia and phonophobia;

      3. Visual aura.