Vertigo and migraine are among the most frequently encountered neurological complaints in /clinical practice, and accumulating evidence supports a strong association between the two conditions.1 Although migraine and vestibular vertigo are both common disorders, their coexistence occurs more frequently than would be expected by chance alone.2 The prevalence of vertigo among individuals with migraine is substantially higher compared to those without headache, indicating that migraineurs are at increased risk of developing vestibular symptoms. This close relationship led to the recognition of a distinct clinical entity known as vestibular migraine, which is characterized by recurrent vestibular symptoms occurring in patients with a current or past history of migraine headache.3Vestibular migraine has now been established as an independent diagnostic condition and is considered one of the most common causes of episodic vertigo. It includes both definite and probable forms, based on the presence and temporal relationship of vestibular symptoms and migraine features. Despite increasing awareness, vestibular migraine remains underdiagnosed in routine clinical practice. A major contributing factor to this underdiagnosis is the wide variation in the temporal relationship between vertigo and migraine headache.4 In many patients, migraine headache precedes the onset of vestibular symptoms by several years, with a long interval separating the two manifestations. In contrast, a smaller proportion of patients experience vertigo before the development of migraine headache5,6. Additionally, some patients report vestibular symptoms occurring simultaneously with migraine attacks, while others experience vertigo episodes completely independent of headache. Notably, the majority of patients with vestibular migraine do not experience headache during every vertigo episode. In some individuals, vestibular symptoms may persist or appear years after migraine headaches have diminished or resolved.7 As a result, patients often fail to spontaneously report a history of migraine when presenting with vertigo. This lack of symptom reporting is further compounded by the tendency of clinicians to focus primarily on vestibular complaints without systematically inquiring about associated migraine features.8 Consequently, the diagnosis of vestibular migraine is frequently overlooked or delayed, leading to misdiagnosis and inappropriate management. Understanding the temporal patterns between vertigo and migraine is therefore crucial for improving diagnostic accuracy and optimizing patient care. Identifying whether vertigo precedes, follows, coincides with, or occurs independently of migraine headache may provide important insights into disease mechanisms and clinical heterogeneity.9 Moreover, clarifying these patterns can assist clinicians in recognizing vestibular migraine in patients who present predominantly with vestibular symptoms and minimal headache complaints. AIM The aim of this study was to describe and compare the clinical features of patients with vestibular migraine based on different temporal patterns of vertigo and migraine headache.

This observational study was conducted in the Department of ENT in RNT Medical college in 1 year from may 2024 to may 2025. Adult patients attending the outpatient clinics with complaints of recurrent vertigo or vestibular symptoms, with or without associated migraine headache, were screened for eligibility. After obtaining informed consent, patients fulfilling the diagnostic criteria for definite or probable vestibular migraine were enrolled. A detailed clinical evaluation was carried out using a structured proforma, which included demographic details, migraine history, characteristics of vestibular symptoms, and the temporal relationship between vertigo and migraine headache. Relevant neurological examinations and necessary investigations were performed to exclude other causes of vertigo. Patients aged 18 years and above who met the diagnostic criteria for definite or probable vestibular migraine and were willing to participate were included in the study. Individuals with other causes of vestibular disorders such as benign paroxysmal positional vertigo, Ménière’s disease, or posterior circulation transient ischemic attack were excluded. Additional exclusion criteria included a history of head trauma, severe systemic illness, abnormal findings on brain imaging, alcohol or drug abuse, other primary or secondary headache disorders, vestibular symptoms associated with chronic anxiety, and a past history of intracranial infection. At enrollment, the temporal relationship between migraine and vertigo was assessed and classified as: (A) migraine onset preceding vertigo, with subtypes including a symptom-free interval, direct transition, or gradual transformation into vertigo; (B) vertigo onset preceding migraine; and (C ) vertigo occurring in association with headache. In group (A), headache characteristics before the onset of vertigo, such as frequency, duration, intensity, and associated symptoms, were additionally recorded.

Table 1: Age Distribution of Study Groups (N = 153) Age group (years) Number of patients Percentage (%) 18–29 29 19.0 30–39 40 26.1 40–49 43 28.1 50–59 30 19.6 ≥60 11 7.2 The study population was distributed across different age groups, with the majority of patients aged 40–49 years (28.1%), followed by those aged 30–39 years (26.1%) and 18–29 years (19%). Older patients aged 50–59 years accounted for 19.6%, while only a small proportion (7.2%) were 60 years or older. Table 2:Age of Onset of Migraine in the Study Population (N = 153) Age group at onset of migraine (years) Number of patients Percentage (%) <20 17 11.1 20–29 48 31.4 30–39 55 35.9 40–49 24 15.7 ≥50 9 5.9 The onset of migraine was most common between 30–39 years (35.9%) and 20–29 years (31.4%), while fewer patients experienced onset before 20 years (11.1%). Late-onset migraine was less frequent, with 40–49 years accounting for 5.7% and ≥50 years for 5.9% of cases. TABLE 3: Clinical Characteristics According to Temporal Patterns (N = 153) Variables Group A (n = 69) Group B (n = 42) Group C (n = 42) Family history of vertigo, n (%) 13 (18.8%) 11(26.2%) 17(40.5%) Family history of migraine, n (%) 22(31.9%) 14(33.3%) 21(50.0%) History of motion sickness, n (%) 30(43.5%) 24 (57.1%) 38(90.5%) Family history of vertigo and migraine was more common in Groups B and C, with Group C showing the highest prevalence (vertigo 40.5%, migraine 50%). Additionally, a history of motion sickness was notably higher in Group C (90.5%) compared to Groups A (43.5%) and B (57.1%), indicating a strong association with vestibular symptoms. TABLE 4:Vestibular Symptoms Among Study Groups Vestibular symptoms Group A (n = 69) Group B (n = 42) Group C (n = 42) Frequency (attacks/3 months), median (IQR) 4 2 3 Duration (hours), median (IQR) 5 4 18 Spontaneous vertigo, n (%) 48 (70%) 11 (26%) 13 (31%) Positional vertigo, n (%) 36 (52%) 9(21%) 10(24%) Head-motion dizziness with nausea, n (%) 31(45%) 15(36%) 26(62%) Visual or head-motion vertigo, n (%) 5(7%) 2(5%) 3(7%) Severe vertigo, n (%) 43(62%) 25(60%) 26(62%) Vestibular symptoms varied across the groups, with Group A showing the highest frequency of spontaneous (70%) and positional vertigo (52%), while Group C had longer median duration of vertigo (18 hours) and higher rates of head-motion dizziness with nausea (62%). Severe vertigo was common in all groups, affecting around 60–62% of patients. TABLE 5:Headache Characteristics Among Study Groups Headache features Group A (n = 69) Group B (n = 42) Group C (n = 42) Frequency (attacks/3 months) 4 5 7 Duration (hours) 10 22 24 Intensity (VAS) 6 8 5 Nausea, n (%) 34 (49%) 15(36%) 39(93%) Vomiting, n (%) 22(32%) 13(31%) 31(74%) Photophobia, n (%) 29(42%) 19(45%) 23(55%) Phonophobia, n (%) 58(84%) 20(47%) 27(64%) Osmophobia, n (%) 6(9%) 8(19%) 10(24%) Headache features differed among the groups, with Group C experiencing the highest frequency (7 attacks/3 months) and longest duration (24 hours), while Group B had the highest intensity (VAS 8). Symptoms such as nausea, vomiting, photophobia, phonophobia, and osmophobia were most prevalent in Group C, particularly nausea (93%) and vomiting (74%). TABLE 6: Headache Features Before and After Onset of Vertigo (Group A Only, n = 69) Headache features Before vertigo After vertigo Frequency (attacks/3 months) 7 4 Duration (hours) 31 25 Intensity (VAS), median (IQR) 8 6 Nausea, n (%) 38(55%) 36(52%) Vomiting, n (%) 31(45%) 30(43%) Photophobia, n (%) 28(41%) 23(33%) Phonophobia, n (%) 21(30%) 18(26%) Headache features were more severe before vertigo, with higher frequency (7 attacks/3 months), longer duration (31 hours), and greater intensity (VAS 8) compared to after vertigo. Associated symptoms including nausea, vomiting, photophobia, and phonophobia also decreased slightly following vertigo episodes. TABLE 7: Psychiatric Comorbidities among Study Groups Psychiatric disorders Group A (n = 69) Group B (n = 42) Group C (n = 42) Anxiety, n (%) 26(38%) 18(43%) 30(71%) Depression, n (%) 30(44%) 21(50%) 33(79%) Sleep disorders, n (%) 42(61%) 23(55%) 17(41%) PPPD, n (%) 28(41%) 29(69%) 39(93%) Psychiatric disorders were more prevalent in Group C, with high rates of anxiety (71%), depression (79%), and PPPD (93%), while Groups A and B showed lower but notable prevalence. Sleep disorders were most common in Group A (61%) and less frequent in Group C (41%), indicating variable psychiatric involvement across the groups.

The study population was distributed across different age groups, with the majority of patients falling within the 40–49 years age range, accounting for 28.1% of the total. This was followed by the 30–39 years group, which comprised 26.1% of patients, indicating a significant representation of middle-aged adults. Younger adults aged 18–29 years formed 19.0% of the cohort, while those in the 50–59 years range also contributed 19.6%, showing notable involvement of the older middle-aged population. Patients aged 60 years and above constituted the smallest proportion, at 7.2%, highlighting that the elderly were less frequently represented in the study. Beh SC, Masrour S, Smith SV, Friedman DI et al10 One hundred and thirty-one patients (105 women) were identified. Mean age of VM onset was 44.3 (±13.7) years. The onset of migraine in the study population varied across different age groups. A small proportion of patients (11.1%) experienced migraine onset before 20 years of age. The majority of cases had onset between 20 and 39 years, with 31.4% in the 20–29 years group and 35.9% in the 30–39 years group, indicating that early adulthood is the most common period for migraine onset. Fewer patients reported onset in the 40–49 years age group (5.7%), and only 5.9% had their first migraine at 50 years or older. In the study, a family history of vertigo was observed in 18.8% of patients in Group A, 26.2% in Group B, and 40.5% in Group C, indicating a higher prevalence in Group C. Similarly, a family history of migraine was reported in 31.9% of Group A, 33.3% of Group B, and 50% of Group C, showing an increasing trend across the groups. History of motion sickness was present in 43.5% of Group A, 57.1% of Group B, and 90.5% of Group C, highlighting a strong association with Group C.The progressively higher percentages from Group A to C indicate that patients in Group C have a more significant familial and personal predisposition. Vestibular symptoms varied across the three groups, with Group A experiencing the highest median frequency of attacks (4/3 months) compared to Groups B (2) and C (3). The duration of vertigo was longest in Group C (18 hours), whereas Groups A and B had shorter durations of 5 and 4 hours, respectively. Spontaneous vertigo was most common in Group A (70%), while positional vertigo also predominated in the same group (52%). Head-motion dizziness with nausea was notably higher in Group C (62%) compared to Groups A (45%) and B (36%). Visual or head-motion vertigo occurred infrequently across all groups. Severe vertigo was reported in similar proportions in Groups A (62%) and C (62%), with Group B slightly lower (60%).Cho SJ, Kim BK, Kim BS, Kim JM, Kim SK et al11 The most common vestibular symptom was head motion-induced dizziness with nausea in VM and spontaneous vertigo in probable VM. The clinical characteristics of VM did not differ from those of migraine without VM. Headache characteristics differed among the groups, with Group C experiencing the highest frequency of attacks (7 per 3 months) and the longest duration (24 hours), whereas Group B had the highest intensity on VAS (8). Nausea and vomiting were most prevalent in Group C (93% and 74%, respectively), while photophobia affected 42–55% of patients across all groups. Phonophobia was particularly high in Group A (84%), but lower in Groups B (47%) and C (64%). Osmophobia was relatively uncommon, ranging from 9% in Group A to 24% in Group C. Headache symptoms were more severe and frequent in Groups B and C compared to Group A. Headache features were generally more pronounced before the onset of vertigo compared to after. The frequency of attacks was higher before vertigo, with a median of 7 attacks per 3 months, decreasing to 4 attacks afterward. Similarly, the duration of headaches was longer before vertigo (31 hours) than after (25 hours). Intensity measured by VAS was also greater before vertigo, with a median of 8 compared to 6 afterward. Gastrointestinal symptoms like nausea and vomiting were slightly more common before vertigo (55% and 45%, respectively) than after (52% and 43%). Sensory symptoms such as photophobia and phonophobia also showed a decrease after vertigo, from 41% to 33% and 30% to 26%, respectively, indicating a reduction in headache severity post-vertigo episodes.Cohen JM, Bigal ME, Newman LC et al12 The most commonly reported symptoms that led to the diagnosis of VM were: unsteadiness (134; 91%), balance disturbance (120; 82%), "light-headedness" (113; 77%), and vertigo (84; 57%). VS and headache occurred concomitantly in 48% of patients. Psychiatric disorders were variably distributed across the groups, with anxiety present in 38% of Group A, 43% of Group B, and 71% of Group C, indicating a higher prevalence in Group C. Depression followed a similar trend, affecting 44% of Group A, 50% of Group B, and 79% of Group C. Sleep disorders were more common in Group A (61%) and Group B (55%), but less frequent in Group C (41%). Persistent postural-perceptual dizziness (PPPD) showed a marked increase from Group A (41%) to Group B (69%) and Group C (93%). Overall, Group C demonstrated the highest burden of psychiatric comorbidities. These findings suggest a strong association between vestibular migraine and psychiatric disorders, particularly in patients with more severe vestibular symptoms.Yan M, Guo X, Liu W, Lu J, Wang J, Hu L et al13 Following the onset of vestibular or headache symptoms, many were diagnosed with anxiety (36.6%), depression (47.7%), PPPD (34.9%) and sleep disorders (70.3%). Except that the proportion of anxiety in group C was higher than that in group A (p < 0.05), no significant difference in the proportion of psychiatric comorbid disorders was found among groups (p: NS)

Vestibular migraine predominantly affects middle-aged adults, with Group C patients exhibiting more severe vestibular and headache symptoms, higher frequency and duration of attacks, and a greater burden of psychiatric comorbidities, including anxiety, depression, sleep disorders, and PPPD. These findings highlight the interplay of genetic predisposition, motion sensitivity, and migraine characteristics in determining the severity and impact of vestibular migraine.

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