Vestibular migraine isn't dizzy migraine: the vertigo is the attack.

The floor takes a slow breath

The room tilts while you're standing at the sink. Not spinning exactly, more like the floor took a slow breath and forgot to put it back. It lasts twenty minutes, then an hour, and your head never hurts once.

You describe it later and someone nods along. Dizzy migraine, right? That one word, dizzy, is where the trouble starts. It shrinks a whole neurological event down to a single sensation, and it quietly tells you the vertigo is a side effect of a headache you didn't even have. If you've been diagnosed, you already know the mismatch between that word and what your body actually does on a bad day.

The Decoupling

Here's the crux the name hides. In vestibular migraine, the vestibular symptoms are the primary event, and the headache is optional. Sometimes it trails the vertigo by hours. Sometimes it doesn't come at all. We call this the Decoupling, because the two things the label glues together, dizziness and head pain, run on separate clocks far more often than the name admits.

That matters clinically and it matters practically. If the attack is the vertigo, then the headache is one feature among several, not the anchor everything else hangs off. Read the criteria closely and that's exactly what they say.

Why 'dizzy migraine' misreads the disease

The phrase dizzy migraine carries a hidden claim: that the vertigo tags along behind head pain, the way photophobia or nausea does. Cross that assumption against the diagnostic definition and it falls apart.

The 2012 Bárány Society and International Headache Society consensus criteria (Lempert et al.) require migrainous features in only half of a person's vestibular episodes. Headache is just one of the qualifying features, sitting alongside the photophobia-plus-phonophobia pairing and visual aura. Do the arithmetic. Half your attacks can carry no headache whatsoever and still be textbook vestibular migraine. So a record that logs the day the headache landed captures the wrong events, and misses the ones with no head pain to timestamp.

Half your attacks can carry no headache at all and still be textbook vestibular migraine.

What the criteria actually require

The 2012 Bárány/IHS criteria are still the diagnostic standard, and they're stricter and stranger than the casual label suggests. Attacks qualify at a duration window of five minutes to 72 hours, which is a range so wide it refuses to behave like a headache. The vestibular symptoms themselves come in flavors: spontaneous internal vertigo (you're moving), spontaneous external vertigo (the room's moving), positional vertigo, head-motion-induced dizziness with nausea, and visually induced vertigo from busy or scrolling visual fields.

Notice what isn't on that list: a mandatory headache. The Bárány Society published a 2022 update to vestibular migraine criteria, but the original 2012 diagnostic criteria were left unchanged; only a literature update was added. ([source](https://pmc.ncbi.nlm.nih.gov/articles/PMC9249276/))

Reading the room, and the differential

Picture a real workup. Forty minutes of the room drifting, a decade-old history of migraine with aura, photophobia during some spells but not this one, no ringing in the ears, no hearing change. That patient reads as vestibular migraine, and the absent headache today doesn't argue against it.

Now swap details and the diagnosis moves. Add fluctuating low-frequency hearing loss, tinnitus, and a plugged-ear feeling, and you're looking at Menière's. Make the spins last seconds and fire only when the head rolls in bed, and it's BPPV. Turn the dizziness into a low, constant unsteadiness that's dragged on for months and worsens in supermarkets and on screens, and it's PPPD. Vestibular migraine is the shape-shifter of the four, which is exactly why it gets flattened into dizzy migraine and why clinicians who work this space, Timothy Hain and Marcello Cherchi among them, spend so much effort teaching the phenotype's breadth.

What changes if the vertigo is the attack

Accept the Decoupling and one thing follows immediately: any record built around the headache is structurally blind to the vestibular half of the disease. It can't count what it never asks about. You end up with a log that says three attacks last month when your body had seven, and the four it dropped were the ones that spun you without ever touching your head.

The between-attack state matters too. Interictal motion sensitivity, visual dependence, the residual imbalance and brain fog that linger for a day or two after the vertigo settles. Those aren't noise. For a lot of people they're the larger share of the burden, and they're invisible to a tool that only opens its eyes when a headache starts.

A timeline that starts before the headache does

We built Postdrome around continuous symptom timelines instead of a headache stopwatch, because the apps we tried kept doing the thing this article is about: they waited for a headache, and the vertigo-only attacks fell through the floor. You can log a spinning episode with no head pain attached to it. You can mark the head-motion dizziness, the visually induced kind in a scrolling feed, the residual unsteadiness and fog that ride out the next 24 to 72 hours after the room stops moving.

Aura Mode is our answer to the harder question underneath all of this: how you're supposed to record any of it when you can't look at a screen without the walls sliding. The point isn't a prettier chart. It's a record your neurologist can actually read, one that shows the disease as it happens to you rather than as a headache tracker imagined it.

What we're watching

Two things sit on our desk. First, whatever refinements the Bárány Society and the broader International Classification of Vestibular Disorders effort land on next, because the 2012 criteria are showing their age against how varied real presentations are. Second, the interictal-burden research, the growing case that the days between attacks carry more of the weight than the field has historically measured. If that's right, the tools built to log discrete headache days are aimed at the wrong target entirely, and the record that wins is the one that never stops watching.