Patients with VM typically report spontaneous or positional vertigo. Some experience a sequence of spontaneous vertigo transforming into positional vertigo after several hours or days. This positional vertigo is distinct from benign paroxysmal positional vertigo (BPPV) with regard to duration of individual attacks (often as long as the head position is maintained in VM versus seconds only in BPPV), duration of symptomatic episodes (minutes to days in VM versus weeks in BPPV) and nystagmus findings [25]. Altogether, 40–70 % of patients experience positional vertigo in the course of the disease, but not necessarily with every attack. A frequent additional symptom is head motion intolerance, i.e. imbalance, illusory motion and nausea aggravated or provoked by head movements [5, 26]. Visually induced vertigo, i.e. vertigo provoked by moving visual scenes such as traffic or movies, can be another prominent feature of VM [5, 27]. Nausea and imbalance are frequent but nonspecific accompaniments of acute VM. The combination of different types of vertigo distinguishes VM from other neuro-otological disorders such as benign paroxysmal positional vertigo or Menière’s disease, which typically present with monosymptomatic vertigo. Patients with VM are often affected by motion sensitivity even in-between attacks [28], which may lead to a chronic type of vestibular dizziness [25]. Another factor contributing to chronic vestibular migraine is secondary psychiatric morbidity, particularly anxiety disorders [29, 30]. These two components of interictal dizziness may not be easily discriminated in individual patients [31].

VM often misses not only the duration criterion for an aura as defined by the ICHD but also the temporal relationship to migraine headaches: vertigo can precede headache as would be typical for an aura, may begin with headache or may appear late in the headache phase. Many patients experience attacks both with and without headache [4, 6, 7]. Quite frequently, patients have an attenuated headache with their vertigo as compared to their usual migraine [3, 6]. In some patients, vertigo and headache never occur together [4, 6, 8]. Misdiagnosis of VM as “cervical vertigo” may occur when accompanying pain is mainly or exclusively localized in the neck, which is quite common in patients with migraine [32].

Along with the vertigo, patients may experience photophobia, phonophobia, osmophobia and visual or other auras. These phenomena are of diagnostic importance, since they may represent the only apparent connection of vertigo and migraine. Patients need to be asked specifically about these migraine symptoms since they often do not volunteer them. A dizziness diary can be useful for prospective recording of associated features.

Auditory symptoms, including hearing loss, tinnitus and aural pressure, have been reported in up to 38 % of patients with VM [2, 5, 6, 33, 34]. Hearing loss is usually mild and transient, without or with only minor progression in the course of the disease [6]. About 20 % develop mild bilateral downsloping hearing loss over the years [35]. In contrast, unilateral moderate to severe hearing loss starting in the low-frequency range would rather favour a diagnosis of Menière’s disease.

Asking for migraine-specific precipitants of vertigo attacks may provide valuable diagnostic information, e.g. provocation by menstruation, deficient sleep, excessive stress, skipped meals, lack of fluid and exposure to sensory stimuli, such as bright or scintillating lights, intense smells or noise. The influence of specific foods and weather conditions is probably overestimated. Sometimes, migraine accompaniments and typical precipitants may be missing, but VM is still considered the most likely diagnosis after other potential causes have been investigated and appear unlikely. In this case, a favourable response to antimigraine drugs may support the suspicion of an underlying migraine mechanism. However, apparent efficacy of a drug should not be regarded as a definite confirmation of the diagnosis, since spontaneous improvement, placebo response and additional drug effects (e.g. anxiolytic or antidepressant) have to be taken into account.