Differences Between Vestibular Migraine and Meniere's Disease Based on Cochlear-Vestibular Function Assessment: A 6-Year Retrospective Clinical Study

Summary

This article presents a protocol to differentiate vestibular migraine (VM) and Meniere's disease (MD) using cochlear-vestibular function assessments, including pure tone audiometry and videonystagmography (VNG), providing evidence for clinical differential diagnosis.

Abstract

Audiological and vestibular function tests are the most commonly used noninvasive evaluation methods for vertigo diseases. Preliminary studies have shown that detailed medical history, audiological, and vestibular function evaluation are effective methods to distinguish Meniere's disease and vestibular migraine diseases. This study retrospectively included 503 patients with vestibular migraine and 1,125 patients with Meniere's disease. Patients underwent pure tone audiometry and videonystagmography (VNG), including spontaneous nystagmus testing and the caloric test. In our study, we found that patients with Meniere's disease often exhibit abnormal unilateral weakness, while those with vestibular migraine show changes in vestibular function characterized by labyrinthine hyperactivity. Compared to vestibular migraine patients, Ménière's disease patients are more likely to experience unilateral full-frequency hearing loss. This study systematically compared the vestibular function and audiological characteristics of vestibular migraine and Ménière's disease, providing an evidence-based foundation for clinical differential diagnosis.

Introduction

Vestibular migraine (VM) and Ménière's disease (MD) are the two most common paroxysmal vertigo disorders encountered in clinical practice. Both conditions are classified as paroxysmal vestibular syndromes in the International Classification of Vestibular Disorders (ICVD)¹. Epidemiological surveys indicate that the global prevalence of VM ranges from 1% to 2.7%², which is significantly higher than that of MD, with a prevalence of 0.2% to 0.5%³. Although the Barany Society has developed diagnostic criteria for both VM and MD to facilitate standardized diagnosis worldwide^4,5, both conditions share recurrent vertigo as their core symptom. The overlap of clinical symptoms, such as hearing loss and tinnitus, combined with the absence of highly specific biomarkers, still poses significant challenges for clinicians in distinguishing between the two disorders.

In recent years, advancements in neuroimaging and molecular biology have provided new insights into the mechanisms underlying VM and MD. For instance, functional magnetic resonance imaging (fMRI) has revealed that patients with VM exhibit abnormal functional connectivity within the vestibular cortical network, suggesting that central sensitization plays a key role in its pathogenesis⁶. In contrast, endolymphatic hydrops (EH), the pathological basis of MD, may be associated with abnormal expression of aquaporin (AQP) and local inflammatory responses⁷. Additionally, the differential expression of novel biomarkers, such as serum calcitonin gene-related peptide (CGRP) and interleukin-6 (IL-6), in VM and MD offers potential support for differential diagnosis^8,9. While these methods show promise in distinguishing between VM and MD, they require expensive detection equipment and incur high diagnostic costs, which makes comprehensive clinical diagnosis and treatment challenging, particularly in primary healthcare settings.

At present, the clinical differentiation between VM and MD primarily relies on a detailed medical history, along with assessments of audiological and vestibular function. Previous studies¹⁰ compared the results of the video head impulse test (vHIT) and the caloric test (CT) in patients with VM and MD, revealing that the CT is particularly useful in distinguishing between these two conditions. However, these studies only evaluated the function of the horizontal semicircular canal using vHIT and CT, without assessing the intensity of nystagmus or the audiological characteristics triggered by the CT. Another study showed that patients with MD often exhibited a dissociation between the results of the vHIT and CT, while those with VM had a low incidence of abnormal findings in the CT¹¹. Most previous research has focused on single-parameter analysis, such as the unilateral weakness rate in CT, while the comprehensive value of multiple parameters (including total labyrinth response, directional preponderance, audiological data, etc.) remains largely unexplored.

This study aims to establish an objective diagnostic framework for the differential diagnosis of VM and MD through a systematic analysis of vestibular-auditory functional differences, referencing the diagnostic criteria of the Barany Society^4,5. The study uses Videonystagmography (VNG) and pure-tone audiometry as non-invasive assessment tools, which can quantify peripheral vestibular function and auditory damage, both of which have been corroborated by several studies^12,13,14. Compared to MRI or biomarker testing, these functional assessments are more cost-effective, accessible, and particularly suitable for primary healthcare settings. Based on these findings, this approach is effective for rapid screening of newly diagnosed patients with vertigo, and when combined with the patient's history, can enhance diagnostic accuracy.

Protocol

The study was approved by the ethical review board of Sun Yat-sen Memorial Hospital of Sun Yat-sen University (No.SYSKY-2025-572-01). Written informed consent was waived because of this retrospective analysis.

A total of 1,628 patients diagnosed with VM and MD at the Vertigo Diagnosis and Treatment Center of Sun Yat-sen Memorial Hospital, Sun Yat-sen University, between August 1, 2018, and July 31, 2024, were included in this study. This cohort consisted of 1,125 cases of MD and 503 cases of VM.

1. Patient Selection

1. Inclusion criteria
   1. VM group: Include patients who meet the diagnostic criteria for Meniere's disease as outlined by the International Barany Society in 2015⁵.
   2. MD group: Include patients who meet the diagnostic criteria for vestibular migraine as outlined by the International Barany Society in 2015⁴.
2. Exclusion criteria
   1. Exclude patients with coexisting central nervous system disorders (e.g., stroke, multiple sclerosis).
   2. Exclude patients who are taking vestibular suppressants or anti-anxiety medications.
   3. Exclude patients with dual diagnosis (both VM and MD).

2. Audiometric testing

1. Instruct patients to perform pure-tone audiometry (the hearing test): Seat patients comfortably in an acoustically insulated room complying with ISO 8253-1 standards (background noise ≤ 30 dB).
2. Fit calibrated headphones, explain responding to audible tones (e.g., raise hand/press button when hearing beeps).
3. Present tones at varying frequencies (125-8000 Hz) and intensities, starting at a faint level, adjust based on responses to determine the softest audible sound (audiometric threshold) for each frequency.
4. Record thresholds systematically to generate an audiogram.

3. Videonystagmography (VNG) test

NOTE: Vestibular function and nystagmus were evaluated using VNG, including Spontaneous nystagmus (SN) test, Supine roll test, Dix-Hallpike test, and CT conducted with the VertiGoggles-M system (see Table of Materials).

1. SN Test
   1. Instruct the patient to remain in a dark environment while wearing an eye mask. Keep the eyes open for 1 min to observe any spontaneous nystagmus.
   2. Record the direction and slow-phase velocity of the nystagmus. Measure the slow-phase velocity (SPV) in degrees per second (°/s). Define an abnormal result (SN+) as an SPV greater than 6°/s¹⁵. Calculate SPV using VNG software.
   3. Evaluate the rhythm of nystagmus (regular vs. irregular) and fixation suppression (reduced vs. enhanced).
      NOTE: Peripheral nystagmus was defined as unidirectional with regular rhythm and reduced fixation suppression; central nystagmus was defined as direction-changing with irregular rhythm and enhanced fixation suppression.
2. Dix-Hallpike and Supine roll test
   1. Dix-Hallpike test
      1. Instruct the patient to rotate their head 45° to the left, then recline backward with the head at a 30° angle to the horizontal plane. Observe for nystagmus using VNG in a dimly lit room (to minimize visual fixation). The VNG system tracks eye movements via infrared cameras, recording nystagmus direction, velocity, and duration automatically
      2. Next, instruct the patient to rotate their head 45° to the right and recline backward, maintaining the same 30° angle to the horizontal plane, and again observe for nystagmus. The nystagmus should be monitored for at least 2 min in each position.
         NOTE: If nystagmus is observed in any of the aforementioned head positions, the result is considered positive.
   2. Supine Roll Test
      1. Instruct the patient to lie in the supine position, with the head elevated 30°; the supine position and then the head turned max to the left; the supine position and then the head turned max to the right. Observe the nystagmus for at least 2 min at each position.
         NOTE: If there is no nystagmus in any of the above positions, it is judged as negative; If the patient's head position shows Direction-changing positional nystagmus on both the left and right sides, it is judged as positive.
3. Caloric test
   NOTE: We selected air calorics to improve patient tolerance and reduce the risk of dizziness. Although water calorics offers slightly higher accuracy, previous studies have shown that the diagnostic efficacy of air calorics is comparable to that of water calorics¹⁶, while also offering advantages such as ease of operation and a lower risk of infection. Additionally, this confirms its consistency with vHIT¹⁷.
   1. Instruct the patient to lie in the supine position, with the head elevated 30°, keeping their eyes open.
   2. Irrigate the ear canal with cold air at 24 °C and warm air at 50 °C for 60 s.
   3. The perfusion order is as follows: Right ear cold air (RC), Left ear cold air (LC), Right ear warm air (RW), and Left ear warm air (LW).
      NOTE: Each irrigation lasted 60 s.
   4. After each perfusion, ensure the subject remains still until the nystagmus subsides before proceeding to the next irrigation.

Results

Baseline characteristics
A total of 503 patients with VM and 1,125 patients with MD were included in the study. The average age of onset for the VM group was 45.89 ± 18.16 years, whereas the average age of onset for the MD group was 51.63 ± 14.29 years. A significant difference was observed between the two groups (P < 0.001). The proportion of women in the VM group was 76.1%, significantly higher than the 59.3% in the MD group (P < 0.001) (Table 1, Figure 1...

Discussion

This study ensured result accuracy and reliability through key measures: pure tone audiometry in ISO 8253-1 compliant sound-insulated rooms (background noise ≤30 dB) with calibrated headphones; VNG using VertiGoggles-M to track eye movements in dimly lit Dix-Hallpike/supine roll tests. A notable modification was using air instead of water calorics, balancing accuracy with better operability, patient tolerance, and lower infection risk. Patient cooperation was ensured via instructions and training to avoid ...

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Pure tone audiometer	Interacoustics	AC40
Sound-proof booth	Acoustic Systems	AS-2018
Video-nystagnography system	ZEHNIT Medical Technology	VertiGoggles-M system