Vestibular migraine. Clinical and diagnostic challenges, and emerging therapeutic approaches

PURPOSE OF REVIEW: Vestibular migraine (VM) is a prevalent yet underdiagnosed cause of vestibular symptoms, which overlaps with other vestibular and migraine-related conditions. This review focuses on detailed clinical phenomenology, alongside comorbidities, and the appraisal of emerging therapies. RECENT FINDINGS: Recent work shows that migraine-associated features such as allodynia, photophobia, and movement sensitivity sharpen clinical discrimination. Premonitory and cognitive symptoms, including brain fog and executive slowing, are increasingly recognized. Chronobiological factors such as menstrual cycle and menopause modulate susceptibility. Oculomotor assessment and neuroimaging point to disturbed integration across vestibular, sensorimotor, and visual networks rather than focal lesions. Comorbid persistent postural-perceptual dizziness, dysautonomia, and autoimmune tendencies complicate diagnosis and management. Early trials support calcitonin gene-related peptide (CGRP) monoclonal antibodies and onabotulinumtoxin-A, with lifestyle interventions, and nutraceuticals commonly being used, although clinical trial designs and endpoints remain heterogeneous. SUMMARY: VM reminds us that bedside examination remains the anchor: a detailed history, eye-movement examination, and context refine diagnosis. Objective markers and interdisciplinary strategies assist rather than replace clinical judgement. Further studies should integrate multimodal assessment and phenotype-guided treatment stratification.