Article · 4 min read
The Bárány Society criteria don't require head pain, yet 'no headache means it isn't migraine' keeps sending people to the wrong diagnosis for years.
The floor tilts in the cereal aisle. Not vertigo like a carnival ride, more like the ground quietly stopped being level and nobody warned you. The shelves lean a few degrees off true, the fluorescent light presses against the back of your eyes, your stomach rolls. Nothing hurts. No headache, no throb, no pain to point a doctor at. You grip the shelf, wait it out, and weeks later someone tells you it was probably anxiety, or an inner-ear thing, or stress.
Vestibular migraine is a migraine that expresses itself in the balance system instead of the pain system. The same neural machinery that makes a classic migraine light-sensitive, sound-sensitive, and nauseated can misfire through the vestibular pathways that tell you where your head is in space. The output shows up as dizziness, room-spinning or rocking vertigo, motion intolerance, a steady pull toward the nearest wall. Some people get head pain in the same attack. Many get it only sometimes. A real subset never get it at all and still meet the diagnostic criteria for migraine. The dizziness is the attack.
The head pain is optional. The migraine is not.
Two framings do the damage. The nickname 'dizzy migraine' files the whole condition under a single symptom, as if it were an ordinary migraine with a side of wooziness. The balance disturbance is the main event, and the headache, when it shows up, plays the side character.
The second framing is the expensive one. Because clinical intuition still ties migraine to head pain, an attack with no headache falls off the differential. Patients get worked up for Meniere's disease, benign positional vertigo, or anxiety instead. Vestibular migraine is the most common cause of recurrent spontaneous vertigo in adults, and it is still routinely missed because the pain the diagnosis is 'supposed' to have never arrived.
There is a written standard, and it settles the argument. In 2012 the Bárány Society and the International Headache Society published consensus diagnostic criteria for vestibular migraine, later carried into the ICHD appendix. Read criterion C carefully. It asks for migraine features in at least half of the vestibular episodes, and it counts light and sound sensitivity or visual aura as qualifying features on their own. A headache is one option among several, and it is required in half of attacks, not all. Nowhere do the criteria demand head pain in every attack. The people telling you it cannot be migraine because nothing hurt are arguing against the definition.
| Criterion | What it requires |
|---|---|
| A | At least 5 episodes of moderate or severe vestibular symptoms lasting 5 minutes to 72 hours |
| B | A current or past history of migraine, with or without aura (per ICHD) |
| C | At least one migraine feature (migraine-type headache, light and sound sensitivity, or visual aura) during 50% or more of the vestibular episodes |
| D | Not better explained by another vestibular or ICHD diagnosis |
Picture a bad-sleep night after a pressure-drop front moves through. By mid-morning the head-motion intolerance starts: turn to check a mirror, look down at a phone, and the room lags behind your eyes. Busy visual environments make it worse, which is why the grocery aisle and the scrolling screen are such reliable triggers. The acute phase can run twenty minutes or stretch toward a day. Sometimes a headache joins late. Often it does not.
Then the attack 'ends' and the tail begins. Flattened energy, word-finding trouble, a brain-fog haze, a residual unsteadiness that makes stairs feel negotiable rather than automatic. That after-phase can outlast the vertigo by a day or more, and it is the part that gets logged nowhere.
Getting the right name is not paperwork. The migraine label moves a vestibular problem onto migraine's whole toolkit: preventive medication classes used for migraine, trigger and sleep work, vestibular rehabilitation therapy, the CGRP conversation with a headache specialist instead of a dead-end anxiety referral. It also changes what is worth writing down. If you only record attacks that hurt, a headache-free vestibular pattern stays invisible to you and to your clinician, and invisible patterns do not get treated.
Here is where most trackers quietly fail this audience. Their data model starts at a headache entry: rate the pain, mark the location, log the triptan. An attack that arrives as vertigo with no pain has no home in that schema, so it lands in a notes field or goes unrecorded.
We built Postdrome around the opposite assumption. Vestibular symptoms, dizziness, motion intolerance, residual photophobia get first-class entries, not an afterthought. Aura Mode exists because logging while the room is moving and the screen is unbearable is its own problem. And the after-phase gets tracked as its own timeline, so the days that vertigo steals stop disappearing from your record.
Two things on the desk right now. The diagnostic-delay research, because the gap between a first attack and a correct label still runs long for many patients, often into years Vestibular migraine is diagnosed with an average delay of 8.4 years after the first onset of migraine. ([source](https://www.frontiersin.org/journals/neurology/articles/10.3389/fneur.2021.812678/full)), and shortening it is the whole point of a piece like this. And Apple's HealthKit vestibular categories, which decide how cleanly a dizziness timeline can move between an app, a clinician, and you.
Postdrome was built by people who watched migraine sit heavily in the lives of people they love, and who kept trying trackers that had no way to log an attack that never became a headache. Vestibular symptoms and the after-phase are first-class here, priced once, kept on your device.