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Vol.:(0123456789)Journal of Neurology (2025) 272:558 https://doi.org/10.1007/s00415-025-13291-xORIGINAL COMMUNICATIONDiagnostic challenges in vestibular migraine—clinical dif f erentiation from Menière’s disease and discrepancies with current classif i cation criteriaDoreen Huppert 1,2  · Eva Grill 1,3  · Sandra Becker?Bense 1,2  · Andreas Zwergal 1,2  · Ralf Strobl 1,3 Received: 3 June 2025 / Revised: 16 July 2025 / Accepted: 20 July 2025 / Published online: 5 August 2025 © The Author(s) 2025AbstractBackground Vestibular migraine (VM) and Menière’s disease (MD) are spontaneous episodic vestibular syndromes and often present with overlapping features, making clinical dif f erentiation challenging. This study aimed to (1) identify key features distinguishing VM from MD and (2) investigate discrepancies between expert diagnosis and International Classif i cation of Vestibular Disorders (ICVD) criteria for VM.Methods We analyzed data from patients diagnosed with VM or MD at the tertiary dizziness center of LMU Munich. Diag-nostic classif i cation was based on ICVD criteria and expert judgment. Symptoms, vestibulo-ocular ref l ex (VOR) function, and demographics were compared. A conditional inference tree identif i ed key dif f erentiators. For ‘suspected VM’ cases not meeting ICVD criteria, reasons for diagnostic discrepancy were analyzed.Results We included 290 patients: 188 with VM and 88 with MD. VM was more common in women (72% vs. 51%) and had an earlier onset (39.6 vs. 49.9 years). MD patients had more rotational vertigo, greater caloric asymmetry, and lower VOR gains on video head impulse testing (all p < 0.0001). The tree identif i ed seven key variables and achieved 86% accuracy. Sixty-six VM patients were diagnosed as ‘suspected VM’ based on expert judgment. Discrepancies were primarily due to short attack duration and atypical symptoms.Conclusions This study identif i ed seven clinical variables to ef f ectively distinguish VM from MD. While VM and MD share overlapping features, diagnostic ambiguity remains common, particularly in cases not meeting ICVD criteria. Our fi ndings support the introduction of a ‘suspected VM’ category to capture patients with atypical presentations not covered by ICVD criteria.Keywords Vestibular migraine · Episodic vestibular disorder · Menière’s disease · Headache · VertigoIntroductionThe two most common spontaneous episodic vestibular syn-dromes are vestibular migraine (VM) with a lifetime preva-lence of 1% [1], followed by Menière’s disease (MD) [2]. VM and MD are sometimes dif f i cult to dif f erentiate, even for an experienced clinician after thorough history taking and clinical examination. Previously assumed dif f erentiation criteria such as endolymphatic hydrops (EH) on contrast-enhanced high-resolution temporal bone MRI no longer pro-vide a reliable basis for dif f erentiation. While EH has been well-documented in MD [3–6], it recently was also found in patients with VM and other vestibular disorders [7–10].This diagnostic ambiguity has prompted the develop-ment of standardized clinical criteria. In 2012 resp. 2015 diagnostic criteria for VM and MD were formulated with the framework of the International Classif i cation of Ves-tibular Disorders (ICVD) by the International Bárány Society for Neuro-Otology [11–13] and were revised for VM in 2022 with regard to a literature update, but without essentially changing the criteria [14] (see Table 1 for an Doreen Huppert and Eva Grill contributed equally. * Ralf Strobl ralf.strobl@med.uni-muenchen.de1 German Center for Vertigo and Balance Disorders (DSGZ), LMU University Hospital, LMU Munich, Munich, Germany2 Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany3 Institute for Medical Information Processing, Biometrics and Epidemiology, LMU Munich, Munich, Germany