Role of Clinical and Instrumental Evaluation in Patients with Vestibular Migraine: a Narrative review.

Vestibular migraine (VM) is one of the most common causes of recurrent episodic vertigo, yet it remains a diagnostic challenge because of its marked clinical heterogeneity and the frequent dissociation between vestibular symptoms and headache. Patients may present with spontaneous, positional, visually induced, or motion-triggered vertigo, often in the absence of concurrent migraine headache, leading to under recognition or misdiagnosis in both otoneurological and neurological settings. VM pathophysiology is complex and multifactorial, involving abnormal sensory integration within vestibulo-thalamo-cortical networks, brainstem dysfunction, and altered ion channel and neurotransmitter activity shared with migraine mechanisms. Central vestibular hypersensitivity, impaired habituation, and transient asymmetries in vestibular processing appear to play a key role. Neuro-otological findings are often subtle and variable, ranging from normal examinations to transient central-type nystagmus, positional vertigo mimicking benign paroxysmal positional vertigo, and abnormal ocular motor responses observed during attacks or interictal periods. Diagnosis is currently based on clinical criteria, emphasizing the temporal association between vestibular symptoms and migraine features or history, while instrumental testing mainly serves to exclude alternative vestibular disorders. Triggering factors such as stress, sleep disturbances, hormonal fluctuations, dietary elements, and sensory overload frequently modulate attack occurrence and severity. In this review, we critically reappraise vestibular and neuro-otological instrumental findings and discuss their potential diagnostic value in VM, particularly in clinical scenarios that do not fully satisfy the 2012 diagnostic criteria. Selected instrumental patterns, when interpreted within a pathophysiological framework, may support a more accurate and confident diagnosis of vestibular migraine.