Reply to "Peripheral Contributions to Vestibular Migraine: A CSF-Inner Ear Perspective on Vosbeek et al."

With great interest, we read the letter to the editor of Dr Bulent Mamikoglu in response to our paper “The Differences in Caloric Test and vHIT Results Between Menière’s Disease and Vestibular Migraine: A Systematic Review and Meta-Analysis.” The author of this letter seems to conclude that VM is a disorder of central network modulation that is susceptible to peripheral perturbations, including pressure-coupled perilymph changes and otolith dysregulation, in subsets of patients. This model aligns with (1) CSF–perilymph literature, (2) pressure-linked oval-window mechanics, (3) BPPV comorbidity, and (4) IIH-spectrum associations. The assertion that disorders unrelated to vestibular migraine (VM) or migraine in general provide evidence for vestibular migraine being a peripheral disorder is not supported by current clinical or pathophysiological data. Multiple lines of evidence indicate that vestibular migraine is primarily a disorder of central origin, involving sensitization and altered processing within central vestibular pathways. Functional neuroimaging studies have suggested abnormal connectivity and activity in brain regions responsible for multisensory vestibular integration and sensorimotor control in patients with vestibular migraine, supporting a central mechanism rather than a peripheral vestibulopathy.1,2 Clinical studies have shown that vestibular migraine patients exhibit abnormal sensitivity to vestibular stimuli that implicates central canal-otolith integration, rather than isolated peripheral vestibular dysfunction.3 The overlap between migraine circuits and central vestibular pathways further reinforces the central origin, with the trigeminovascular system and brainstem nuclei playing key roles in symptom generation.4 Regarding the definition of vestibular migraine, there is substantial heterogeneity in clinical presentations. The diagnostic criteria jointly proposed by the Bárány Society and the International Headache Society require a history of migraine and vestibular symptoms that are temporally associated with migraine features; however, they do not, for example, distinguish between separate vestibular episodes in patients with a history of migraine and vestibular complaints occurring during the migraine aura or headache phase.5 Recent cluster analyses and large cohort studies have identified multiple subgroups within vestibular migraine, with variable symptom profiles, attack durations, and associated features, indicating that the current diagnostic entity likely encompasses a heterogeneous group of patients with different underlying mechanisms.6,7 This heterogeneity complicates both diagnosis and management, and underscores the need for further research to refine the classification and understanding of vestibular migraine. In summary, disorders unrelated to vestibular migraine do not provide evidence for a peripheral origin of vestibular migraine, and the current definition likely includes a diverse patient population with both central and peripheral features, but with predominant central pathophysiology.