The Short Answer Educational content only. Any suspected concussion warrants medical evaluation. Consult vestibular-trained physical therapist, neuro-optometrist, or concussion specialist for individualized guidance. Concussion causes vestibular migraine through brainstem excitability changes, trigeminovascular activation, and altered central vestibular processing (Silverberg et al., 2020). Vestibular migraine (VM) affects 30-50% of post-concussion patients with pre-existing migraine or migraine family history. Symptoms include vertigo attacks lasting 5 minutes to 72 hours, motion sensitivity, visual motion sensitivity, and headache. Diagnosis by clinical criteria (Barany Society/International Headache Society): at least 5 episodes of vestibular symptoms of moderate or severe intensity, current or prior history of migraine, and at least one migraine feature during at least 50% of vestibular episodes. Treatment includes migraine prevention medications (topiramate, propranolol, amitriptyline, CGRP antagonists), vestibular rehabilitation, and trigger avoidance. Concussion triggers vestibular migraine via brainstem excitability. Brainstem excitability trigger. 30-50% of PCS patients with migraine history affected. 30-50% with migraine history. Migraine prevention treats vestibular migraine. Migraine prevention treats VM. Vestibular Migraine Diagnostic Criteria At least 5 episodes of vestibular symptoms. At least 5 episodes. Moderate or severe intensity. Moderate or severe intensity. 5 minutes to 72 hours duration. 5 minutes to 72 hours duration. Current or prior migraine history. Current or prior migraine history. At least one migraine feature during 50%+ of episodes. Migraine feature 50%+ episodes. Not better explained by another diagnosis. Not better explained by another diagnosis. How Concussion Triggers Vestibular Migraine Brainstem excitability changes. Brainstem excitability changes. Cortical spreading depression susceptibility. Cortical spreading depression susceptibility. Trigeminovascular activation. Trigeminovascular activation. Central vestibular processing alteration. Central vestibular processing alteration. Serotonergic system disruption. Serotonergic system disruption. CGRP release increased. CGRP release increased. Genetic migraine susceptibility unmasked. Genetic migraine susceptibility unmasked. Symptoms Vertigo attacks (spinning). Vertigo attacks spinning. Non-vertiginous dizziness. Non-vertiginous dizziness. Motion sensitivity. Motion sensitivity. Visual motion sensitivity. Visual motion sensitivity. Head motion intolerance. Head motion intolerance. Positional vertigo. Positional vertigo. Migraine headache concurrent. Migraine headache concurrent. Photophobia during episodes. Photophobia during episodes. Phonophobia during episodes. Phonophobia during episodes. Nausea and vomiting. Nausea and vomiting. Aura possible. Aura possible. Triggers Sleep disturbance. Sleep disturbance. Stress. Stress. Menstruation. Menstruation. Weather changes. Weather changes. Barometric pressure changes. Barometric pressure changes. Dehydration. Dehydration. Skipping meals. Skipping meals. Alcohol. Alcohol. Aged cheese, chocolate, MSG. Aged cheese chocolate MSG. Bright lights. Bright lights. Loud sounds. Loud sounds. Visual patterns. Visual patterns. Preventive Treatment Topiramate 25-100 mg daily. Topiramate 25-100 mg daily. Propranolol 40-160 mg daily. Propranolol 40-160 mg daily. Amitriptyline 10-50 mg nightly. Amitriptyline 10-50 mg nightly. Nortriptyline alternative. Nortriptyline alternative. Verapamil 240-480 mg daily. Verapamil 240-480 mg daily. Venlafaxine 37.5-150 mg daily. Venlafaxine 37.5-150 mg daily. CGRP monoclonal antibodies. CGRP monoclonal antibodies. Onabotulinumtoxin A (Botox). Onabotulinumtoxin A Botox. Acute Treatment Triptans for headache component. Triptans for headache component. Gepants alternative acute. Gepants alternative acute. Meclizine for vertigo. Meclizine for vertigo. Ondansetron for nausea. Ondansetron for nausea. Promethazine for nausea. Promethazine for nausea. Prochlorperazine for nausea. Prochlorperazine for nausea. Vestibular Rehabilitation Vestibular rehab reduces frequency. Vestibular rehab reduces frequency. Habituation exercises. Habituation exercises. Gaze stabilization. Gaze stabilization. Balance training. Balance training. Between-episode training. Between-episode training. Combined with prevention most effective. Combined with prevention most effective. Lifestyle Management Consistent sleep schedule. Consistent sleep schedule. Regular meals. Regular meals. Hydration. Hydration. Stress management. Stress management. Trigger identification and avoidance. Trigger identification and avoidance. Migraine diary. Migraine diary. Exercise. Exercise. Supporting Mobility Routine These exercises support vestibular migraine management through cervical mobility and nervous system regulation. JME 155 Diaphragmatic breathing supports vagal tone and parasympathetic regulation during concussion recovery. 10 breaths every 60-90 minutes. JME 14 Chin tucks reduce upper cervical tension common in concussion injury. 10 repetitions with 5-second holds. JME 1 Cervical rotation supports cerebral blood flow and nervous system regulation. 10 repetitions each direction. JME 150 Thoracic rotation restores breathing depth shallow during concussion recovery. 8 repetitions per direction. Start your 3-day free trial for joint-specific mobility programs that support nervous system regulation through concussion recovery. How is vestibular migraine different from other vestibular disorders? Vestibular migraine features migraine history, migraine symptoms during episodes (photophobia, phonophobia, headache), and responds to migraine treatments. Meniere's disease features hearing loss and tinnitus. BPPV features brief positional vertigo. PPPD features chronic non-vertiginous dizziness. Vestibular migraine episodes 5 minutes to 72 hours duration distinguish from other disorders. Do all vestibular migraine attacks include headache? No. Vertigo without headache common in vestibular migraine. Migraine features (photophobia, phonophobia, aura) required in 50% of episodes for diagnosis, but headache not required each episode. Some patients have alternating vertigo attacks and typical migraine headaches. Diagnostic criteria based on migraine history not headache during each episode. Which migraine prevention medication is best for post-concussion vestibular migraine? Topiramate, propranolol, and amitriptyline first-line. Topiramate best evidence for vestibular migraine specifically. Propranolol addresses concussion-related tachycardia and anxiety. Amitriptyline addresses sleep and mood symptoms. Venlafaxine, verapamil, and CGRP monoclonal antibodies alternatives. Selection based on comorbidities and side effect profiles. Can vestibular migraine resolve after concussion? Vestibular migraine can substantially improve with treatment. Migraine prevention medications reduce frequency 50%+ in responders. Vestibular rehabilitation reduces symptoms. Trigger management reduces episodes. Some patients achieve complete remission. Combined treatment approach most effective. Realistic expectation is significant improvement rather than complete cure. Should I see a neurologist for post-concussion vestibular migraine? Yes. Neurologist or headache specialist supports diagnosis and treatment. Vestibular neurologist ideal. Vestibular-trained physical therapist for rehabilitation. Otolaryngologist to rule out other vestibular disorders. Multidisciplinary approach essential. Concussion clinic coordinates care. References Patricios, J. S., et al. (2023). Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam, October 2022. British Journal of Sports Medicine, 57(11), 695-711. PubMed Silverberg, N. D., et al. (2020). Management of concussion and mild traumatic brain injury: a synthesis of practice guidelines. Archives of Physical Medicine and Rehabilitation, 101(2), 382-393. PubMed