Vestibular migraine (VM) is a neurological condition that causes recurrent episodes of vertigo and dizziness in people with a history of migraines. Unlike a typical migraine, these attacks do not always include a headache. Instead, the primary feature is a disturbance in the inner ear and brain balance centers. The timeline for symptoms is highly unpredictable, ranging from brief moments of unsteadiness to sustained, debilitating periods of spinning. Understanding these variable timelines is important for accurately diagnosing and managing this disorder.
Defining the Acute Duration of Vestibular Migraine Episodes
The duration of a single, acute vestibular migraine attack is defined by specific diagnostic criteria. These criteria require the most intense vestibular symptoms to last between five minutes and 72 hours. This time frame captures the wide spectrum of how long vertigo, the spinning sensation, may persist during an attack. In VM, vertigo is usually rated as moderate or severe, meaning it significantly interferes with daily activities.
Short episodes are common, with approximately 30% of patients experiencing attacks that are over within minutes. Another 30% have attacks lasting hours, while a further 30% experience sustained vertigo over several days, falling within the 72-hour limit. A smaller fraction of attacks may last only seconds, often occurring repeatedly when the head is moved or visually stimulated. This variability means an acute attack can be a fleeting moment of disequilibrium or a multi-day event requiring complete rest.
The most severe symptoms that meet the diagnostic criteria for VM involve true spinning vertigo or significant motion-induced dizziness. Even within the 72-hour window, the episode’s severity can fluctuate, often starting and ending with less intense symptoms. It is important to distinguish these intense, full-blown vertigo attacks from more transient feelings of dizziness.
Understanding Interictal Symptoms and Chronic Vestibular Migraine
Vestibular migraine is fundamentally an episodic disorder, characterized by distinct attacks separated by periods of relative calm. However, it is often a chronic condition, and many patients experience lingering symptoms between acute episodes, known as interictal symptoms. These persistent background symptoms can include mild unsteadiness, visual dependence, or a feeling of constant motion sensitivity.
Many patients report interictal dizziness, with studies indicating that up to two-thirds of individuals with VM may have this persistent symptom. This lingering feeling of imbalance or motion sickness creates a state of low-grade, ongoing vestibular dysfunction. This constant sensitivity can be triggered by complex visual patterns or quick head movements, making the disorder feel like a continuous challenge rather than isolated events.
In some cases, the condition can progress toward Chronic Vestibular Migraine. While diagnostic criteria cap acute attack duration at 72 hours, a small subset of patients report prolonged vestibular symptoms that exceed this limit, lasting for weeks. This chronic presentation involves symptoms that are present most or all of the time, blurring the line between an acute episode and the persistent interictal state.
Factors That Influence Attack Length and Severity
The length and intensity of a vestibular migraine attack are influenced by specific internal and external factors. Identifying and managing personal triggers is a primary strategy for reducing the duration and frequency of episodes. Common triggers include hormonal fluctuations, particularly those related to the menstrual cycle, and lifestyle factors such as poor sleep quality and emotional stress.
A lack of adequate sleep is strongly associated with increased severity of VM attacks. Dietary choices, such as aged cheeses, red wine, or processed meats, can act as chemical triggers that initiate the neurological cascade leading to an attack. The time of day can also play a role, with some evidence suggesting that more severe attacks tend to occur in the early hours of the morning.
Pharmacological interventions are another factor that can directly modify the timeline of an attack. Acute abortive medications, such as triptans or the newer calcitonin gene-related peptide (CGRP) inhibitors, are designed to be taken at the first sign of an attack to stop its progression. When effective, these treatments can significantly shorten the duration of an episode from hours or days to mere minutes, or prevent it entirely.
For individuals with frequent or prolonged attacks, preventive medications are used daily to reduce the overall excitability of the nervous system. Medications like flunarizine, valproate, certain beta-blockers, and antidepressants reduce the frequency, severity, and duration of both vertigo and associated headaches over time. By stabilizing neurological function, these prophylactic treatments decrease the likelihood of an attack reaching its maximum potential duration of 72 hours.
When Extended Symptoms Require Immediate Medical Attention
Although vestibular migraine can cause distressing and prolonged symptoms, certain presentations should immediately raise concern. These symptoms may indicate a serious neurological event, such as a stroke or transient ischemic attack (TIA). The presence of new or severe symptoms that accompany the dizziness warrants an urgent medical evaluation.
Symptoms described as “dizziness plus” are a warning sign, meaning the vertigo is not isolated but occurs alongside other clear neurological deficits. These red flags include:
- Sudden facial drooping.
- Weakness or numbness on one side of the body.
- Difficulty speaking or slurred speech.
- Acute double vision.
While a VM attack can last up to 72 hours, a TIA, or “mini-stroke,” often causes symptoms that are intense but resolve in less than an hour.
If the vertigo or dizziness is severe, persistent, and lasts longer than 72 hours without improvement, it should be investigated promptly, especially if it is the first prolonged episode. The sudden onset of the worst headache of one’s life, loss of consciousness, or an inability to walk should prompt an immediate call for emergency medical help. These acute changes require diagnostic testing to rule out life-threatening conditions.