Subdiagnosis of Migraine Can Predict Balance Problems

June 3, 2020
Gianna Melillo

Gianna is an associate editor of The American Journal of Managed Care® (AJMC®). She has been working on AJMC® since 2019 and has a BA in philosophy and journalism & professional writing from The College of New Jersey.

The subdiagnosis of migraine, but not the presence of vestibular symptoms, can predict balance impairments in migraineurs, according to a study published in The Journal of Headache and Pain.

The subdiagnosis of migraine, but not the presence of vestibular symptoms, can predict balance impairments in migraineurs, according to a study published in The Journal of Headache and Pain.

Balance changes and vestibular symptoms, such as dizziness and vertigo, are common in patients who experience migraine with aura and chronic migraine. Because the co-occurrence of these symptoms with migraine happens during the ictal and interictal periods, they can either be considered part of the migraine presentation or a different classification. Additional research has suggested the presence of aura and headache frequency can predict dizziness.

“The etiology of the disequilibrium in migraineurs is not yet established, but it can be related to the presence of subclinical vestibular and cerebellar dysfunctions, which is verified by otoneurologic alterations and subclinical ischemic-like lesions in the vestibular and cerebellar regions,” the authors explain.

To investigate factors that may explain balance alterations in migraine patients and the presence of aura and chronicity of migraine, researchers had 153 study participants answer a structured questionnaire regarding migraine features and complete the Modified Sensory Organization Test (modified SOT). The modified SOT consisted of 4 conditions of stable and unstable surfaces with open and closed eyes, to measure balance via the displacement area (cm2).

The study was the first of its kind to analyze “the presence of vestibular symptoms and the subdiagnosis contribution in the same statistical model to verify the influence of both in postural control.”

All participants were women between the ages of 18 and 55 and recruited from a tertiary outpatient headache clinic in Brazil.

Of the 153 patients with migraine diagnosed by neurologists, 53 experienced migraine without aura, 49 had migraine with aura, and 51 had chronic migraine according to International Classification of Headache Disorders-III (ICHD-III) criteria. A control cohort of 54 headache-free individuals were included in the study.

Data revealed:

  • Vestibular symptoms were not a significant predictor of sway (F-tests [F]1206.37 = 2.51; P = .114; Bayes Factors [BF] = 0.082)
  • Migraine diagnosis was a significant predictor of sway (F3218.43 = 3.14; P = .026; BF = 42.45)
  • BF provided strong evidence for the presence of an effect of diagnosis on sway, as well as for the absence of an effect of dizziness on sway
  • Patients with migraine with aura exhibit more sway on foam surfaces than migraineurs without aura

Although there was a significant difference between the migraine groups in the unstable surface condition, “the effect-sizes for other pairwise comparisons were similar in magnitude (eg, between controls or migraine without aura versus chronic migraine and migraine with aura),” the researchers said.

“Importantly, meaningful differences across subdiagnosis of migraine groups were only observed under foam, but not firm surface condition,” the authors note.

They conclude that the results provide evidence that diagnosis, not presence of vestibular symptoms, predicts postural sway in migraineurs.

Future studies on postural control and vestibular assessment should be performed in patients with and without vestibular migraine, taking into consideration factors like depression and anxiety.


Zorzin L, Carvalho GF, Kreitewolf J, et al. Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients — a cross sectional study. J Headache Pain. Published online May 24, 2020. doi:10.1186/s10194-020-01128-z