How can I differentiate vestibular migraine from other causes of vertigo in a primary care setting?

Differentiating vestibular migraine from other causes of vertigo in primary care involves careful clinical assessment focusing on symptom patterns, associated features, and exclusion of red flags.

Vestibular migraine typically presents with recurrent episodes of vertigo lasting between 5 minutes and 72 hours, often accompanied by a history of migraine headaches or migraine features such as photophobia, phonophobia, or aura. The vertigo episodes may be spontaneous or triggered by head movements but are not usually provoked solely by positional changes, which helps distinguish it from benign paroxysmal positional vertigo (BPPV) ²,¹.

In contrast, BPPV is characterized by brief episodes of vertigo triggered specifically by changes in head position and can be diagnosed with the Hallpike manoeuvre, which is not a feature of vestibular migraine ². Meniere’s disease often presents with vertigo episodes lasting 20 minutes to several hours, accompanied by fluctuating hearing loss, tinnitus, and aural fullness, which are not typical in vestibular migraine ¹. Vestibular neuronitis usually causes a single prolonged episode of vertigo lasting days without auditory symptoms or headache ¹.

Red flag features that suggest a central cause rather than vestibular migraine include sudden onset vertigo reaching maximal intensity within seconds, persistent vertigo lasting more than 24 hours, new neurological signs (e.g., cranial nerve deficits, ataxia, vertical nystagmus), new unilateral hearing loss, or new severe headache, which warrant urgent referral or hospital admission ¹,².

In primary care, a detailed history emphasizing the duration and triggers of vertigo, associated migraine symptoms, and neurological examination to exclude central signs is essential. If vestibular migraine is suspected but diagnosis is uncertain, referral to a balance specialist (ENT, neurologist, or audiovestibular physician) is recommended for further assessment ¹,². Symptomatic treatment with antiemetics or vestibular suppressants may be offered short term while awaiting specialist input, but these should not delay referral ¹.

Recent interdisciplinary literature supports this approach, emphasizing the importance of excluding central causes and using clinical features to differentiate vestibular migraine from other vertigo etiologies, while noting that vestibular migraine remains a diagnosis of exclusion in many cases (Karatas, 2008; Tarnutzer et al., 2025).