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# Other causes of vertigo: vestibular migraine, PPPD, perilymph fistula, canal dehiscence and motion sickness

- Topic

Beyond BPPV, neuritis and Ménière, vertigo can come from migraine, chronic functional dizziness, inner-ear leaks or a thin canal roof.

Updated Nov 12, 2026

**See it in 3D:** [Semicircular canals](https://durgical.com/en/anatomy/semicircular-canals/) · [Vestibule](https://durgical.com/en/anatomy/vestibule/)

## Key points

- Vestibular migraine: at least 5 episodes of vestibular symptoms lasting 5 minutes to 72 hours, a migraine history and migraine features in at least half of the episodes.
- PPPD: dizziness or unsteadiness on most days for 3 months or more, worse upright, with motion and with busy visual scenes; treated with vestibular rehabilitation, SSRIs or SNRIs and cognitive behavioural therapy.
- Perilymph fistula: vertigo and fluctuating sensorineural hearing loss after barotrauma, head injury, straining or stapes surgery; vertigo with pressure (fistula sign).
- Superior canal dehiscence: vertigo with loud sounds (Tullio) or pressure (Hennebert), autophony, and a «conductive» loss with better-than-normal bone conduction; VEMP thresholds low; CT confirms.
- Motion sickness comes from a mismatch between visual and vestibular signals; prevent with behavioural measures, first-generation antihistamines or scopolamine.
- Mal de débarquement: a rocking feeling after a boat trip or flight that improves while travelling again.

## What it is

Most dizzy patients have BPPV, vestibular neuritis, Ménière disease or a central cause, which have their own pages. This page covers the next group that exams and clinics expect you to recognise. Vestibular migraine causes recurrent vertigo of minutes to days in people with migraine, usually without lasting hearing loss. Persistent postural-perceptual dizziness (PPPD) is a chronic functional disorder with daily unsteadiness for at least three months, often after an acute vestibular event. Perilymph fistula and superior semicircular canal dehiscence are «third window» or leak problems in which pressure or loud sound provokes vertigo. Motion sickness, mal de débarquement and alternobaric vertigo complete the list. Most are diagnosed from the history with a normal or near-normal exam, so the history is the key test.

## Key facts

- Vestibular migraine episodes may come with or without headache; photophobia, phonophobia or a visual aura during the episode support it. Hearing is usually stable, which helps separate it from Ménière disease.
- Vestibular migraine treatment follows migraine care: trigger control, acute migraine drugs and antiemetics, prophylaxis (beta-blockers, tricyclics, topiramate or calcium-channel blockers) and vestibular rehabilitation.
- PPPD is often triggered by BPPV, neuritis, a panic attack or concussion; the exam and tests are usually normal or show only the old, compensated event.
- Perilymph fistula: 20 to 40 % of cases remain without a clear cause; first treatment is bed rest with the head raised and avoiding straining; surgical patching if symptoms persist.
- Superior canal dehiscence: patients may hear their own voice, footsteps or eye movements; audiometry shows a low-frequency air-bone gap with intact acoustic reflexes and a normal tympanogram (unlike otosclerosis).
- Superior canal dehiscence surgery plugs or resurfaces the canal through the middle cranial fossa or the mastoid; round window reinforcement is another option.
- Alternobaric vertigo: short vertigo when middle-ear pressure differs between the two ears during ascent while diving or flying.

## Structure

- Migraine-related: vestibular migraine (formerly migraine-associated vertigo), benign paroxysmal vertigo of childhood.
- Chronic functional: persistent postural-perceptual dizziness (PPPD), often with anxiety.
- Third window and leaks: superior semicircular canal dehiscence, perilymph fistula (oval or round window).
- Motion and pressure: motion sickness, mal de débarquement syndrome, alternobaric vertigo in divers and pilots.
- Always rule out first: BPPV, vestibular neuritis, Ménière disease, posterior circulation stroke, cardiovascular and drug causes.

## Telling these disorders apart

| Disorder | Trigger and duration | Hearing | Key test | First management |
| --- | --- | --- | --- | --- |
| Vestibular migraine | Spontaneous or triggered; 5 minutes to 72 hours | Usually normal | History (Bárány/ICHD criteria); exam normal between attacks | Migraine treatment and prophylaxis, rehabilitation |
| PPPD | Daily, 3 months or more; worse upright and with visual motion | Normal | History; tests normal or show an old event | Vestibular rehabilitation, SSRI/SNRI, cognitive behavioural therapy |
| Perilymph fistula | After pressure, trauma, straining or stapes surgery | Fluctuating sensorineural loss | Fistula sign; CT may show air in the labyrinth | Rest, head up, no straining; surgery if it persists |
| Superior canal dehiscence | Loud sound or pressure; seconds | Low-tone air-bone gap, bone conduction better than normal | VEMP (low threshold), high-resolution CT | Avoid triggers; surgery if disabling |
| Motion sickness | Cars, boats, planes, screens | Normal | History | Behavioural measures, antihistamines, scopolamine |
| Mal de débarquement | After travel; better when moving again | Normal | History | Reassurance, rehabilitation |

## In clinical practice

- Any vertigo with new neurological signs, a new severe headache or inability to walk is treated as central until proven otherwise.
- Sudden hearing loss with vertigo after barotrauma or a blow to the ear suggests a perilymph fistula: same-day ENT assessment.
- Do not label a patient with PPPD before excluding active vestibular, cardiac or neurological disease.
- Avoid long-term vestibular suppressants: they slow central compensation and worsen chronic dizziness.

## Next step / Initial management

- Workup: full history (timing, triggers, migraine features), bedside vestibular exam, pure-tone audiometry; add VNG, vHIT or VEMP when the diagnosis is unclear.
- Vestibular migraine and PPPD are managed in primary care or neurology; refer routinely to ENT, neurology or vestibular rehabilitation when the diagnosis is uncertain or treatment fails.
- Suspected perilymph fistula or superior canal dehiscence: high-resolution temporal bone CT and ENT referral (same day if hearing loss is sudden, otherwise routine).
- Motion sickness: advise looking at the horizon and sitting where motion is least; first-generation antihistamines (dimenhydrinate, meclizine) or scopolamine before travel, warning about drowsiness.
- Central red flags: emergency referral the same hour for stroke workup.

## Test yourself

Think of the answer, then tap the question to see it.

## A 32-year-old woman with migraine has spontaneous vertigo for 4 to 6 hours with photophobia, normal hearing and a normal exam between attacks. Diagnosis?

Vestibular migraine: treat as migraine (trigger control, acute treatment, prophylaxis if frequent) with vestibular rehabilitation.

## Six months after vestibular neuritis a man feels unsteady every day, worse in supermarkets; vHIT is now normal. What is the likely diagnosis?

Persistent postural-perceptual dizziness (PPPD): vestibular rehabilitation, SSRIs or SNRIs and cognitive behavioural therapy.

## A patient hears his own eye movements and gets vertigo with loud music. Audiometry shows a low-tone air-bone gap with present acoustic reflexes. Which study confirms the diagnosis?

High-resolution temporal bone CT in the plane of the superior canal, to show superior semicircular canal dehiscence; VEMP thresholds are low.

## After a deep-sea dive a diver has vertigo, tinnitus and sudden hearing loss in one ear. What must be suspected?

A perilymph fistula (inner-ear barotrauma); same-day ENT assessment, rest with the head raised and no straining, and audiometry.

[Add to my cards (4)](https://durgical.app/estudiar/?add=/en/ent/other-causes-of-vertigo-vestibular-migraine-pppd-perilymph-fistula-canal-dehisce/)

## Elsewhere in DurgiPedia

- [The vestibular system, tone and posture](https://durgical.com/en/physiology/the-vestibular-system-tone-and-posture/)

## Connections

## See it in 3D 2

The structures of Durgical's 3D anatomy where it is found.

- [Semicircular canals](https://durgical.com/en/anatomy/semicircular-canals/)
- [Vestibule](https://durgical.com/en/anatomy/vestibule/)

## Related 5

- [Approach to vertigo: peripheral or central](https://durgical.com/en/ent/approach-to-vertigo-peripheral-or-central/)
- [Bedside vestibular exam: nystagmus, head impulse, HINTS and Dix-Hallpike](https://durgical.com/en/ent/bedside-vestibular-exam-nystagmus-head-impulse-hints-and-dix-hallpike/)
- [Vestibular laboratory tests: calorics, VNG, video head impulse, VEMP and posturography](https://durgical.com/en/ent/vestibular-laboratory-tests-calorics-vng-video-head-impulse-vemp-and-posturograp/)
- [Approach to hearing loss](https://durgical.com/en/ent/approach-to-hearing-loss/)
- [Ear trauma: auricular haematoma, eardrum perforation and temporal bone fracture](https://durgical.com/en/ent/ear-trauma-auricular-haematoma-eardrum-perforation-and-temporal-bone-fracture/)

## Related conditions 4

- [Migraine](https://durgical.com/en/conditions/migraine/)
- [Benign paroxysmal positional vertigo (BPPV)](https://durgical.com/en/conditions/benign-paroxysmal-positional-vertigo/)
- [Ménière disease](https://durgical.com/en/conditions/meniere-disease/)
- [Vestibular neuritis and labyrinthitis](https://durgical.com/en/conditions/vestibular-neuritis-and-labyrinthitis/)

## In Pharmacology 1

- [H1 antihistamines](https://durgical.com/en/pharmacology/classes/h1-antihistamines/)

[← All of ENT](https://durgical.com/en/ent/)

Educational content; it does not replace a medical assessment and is not a clinical instruction. For a real case, follow current guidelines and specialist advice.

Sources: [Migraine-Associated Vertigo](https://www.ncbi.nlm.nih.gov/books/NBK507859/) (StatPearls Publishing (NCBI Bookshelf), 2024); [Persistent Postural-Perceptual Dizziness](https://www.ncbi.nlm.nih.gov/books/NBK578198/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Perilymphatic Fistula](https://www.ncbi.nlm.nih.gov/books/NBK563221/) (StatPearls Publishing (NCBI Bookshelf), 2025); [Tullio Phenomenon](https://www.ncbi.nlm.nih.gov/books/NBK513229/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Motion Sickness](https://www.ncbi.nlm.nih.gov/books/NBK539706/) (StatPearls Publishing (NCBI Bookshelf), 2023); [Alternobaric Vertigo](https://www.ncbi.nlm.nih.gov/books/NBK482211/) (StatPearls Publishing (NCBI Bookshelf), 2026); [Superior canal dehiscence syndrome: a review (Auris Nasus Larynx)](https://pubmed.ncbi.nlm.nih.gov/37640595/) (Auris Nasus Larynx (PubMed), 2024); [Balance Disorders](https://www.nidcd.nih.gov/health/balance-disorders) (National Institute on Deafness and Other Communication Disorders (NIDCD), 2018).

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Representative model, for educational purposes only.

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Source: https://durgical.com/en/ent/other-causes-of-vertigo-vestibular-migraine-pppd-perilymph-fistula-canal-dehisce/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/ent/other-causes-of-vertigo-vestibular-migraine-pppd-perilymph-fistula-canal-dehisce/