Exploring the effectiveness of neuromodulation techniques in the diagnosis and management of vestibular disorders and migraine and its relevance to vestibular migraine

i

This article has been updated. A Correction to this article was published on .

i

The Original Article was published on

i

The Original Article was published on

i

This article has been updated

i

This article was retracted on

i

This article has been updated

Abstract

Vestibular Migraine (VM) is a complex neurological disorder characterized by episodic vertigo and migraine-like symptoms and is often misdiagnosed due to overlapping features with other vestibular and neurological conditions. In this review, we systematically explored the efficacy of exogenous (e.g., repetitive transcranial magnetic stimulation (rTMS) and transient DC Stimulation (tDCS)) and endogenous (e.g., EEG and infra-low frequency neurofeedback) neuromodulation techniques in diagnosing and managing vestibular disorders and migraines, with its relevance to VM. Analysis of 30 selected studies demonstrated promising outcomes in symptom reduction, with notable effectiveness in refractory and chronic cases. Studies involving both neuromodulation techniques improve various symptoms of vestibular disorders and migraine, positioning neuromodulation as a valuable adjunct to the available standard care being employed with patients. Given the pathophysiological overlap between migraine and vestibular dysfunction, particularly involving cortical excitability, GABAergic inhibition, and hypothalamic-trigeminal dysregulation, neuromodulation offers a non-invasive, safe, and targeted approach for long-term VM management. Further high-quality clinical trials are warranted to establish standardized protocols and confirm the long-term efficacy of these neuromodulation modalities.

Keywords

vestibular migraine / repetitive transcranial magnetic stimulation (r-TMS) / Transcranial Direct Current Stimulation (t-DCS) / neuromodulation / migraine episode / inhibition / exogenous / endogenous

CHANGE HISTORY

A Correction to this paper has been published:
https://doi.org

The Retraction Note was updated to reflect reception of statements of disagreement from all authors.

This article has been retracted.Please see the Retraction Notice for more detail:
https://doi.org

References

[1] Strupp M, Dlugaiczyk J, Ertl-Wagner BB, et al. (2020) Vestibular disorders. Deutsch Ärztebl Int 117: 300-310. https://doi.org/10.3238/arztebl.2020.0300

[2] Dieterich M, Obermann M, Celebisoy N, et al. (2016) VM: the most frequent entity of episodic vertigo. J Neurol 263: 82-89. https://doi.org/10.1007/s00415-015-7905-2

[3] Shen Y, Qi X (2022) Update on diagnosis and differential diagnosis of VM. Neurol Sci 43: 1659-1666. https://doi.org/10.1007/s10072-022-05872-9

[4] Lempert T, Neuhauser H (2009) Epidemiology of vertigo, migraine, and VM. J Neurol 256: 333-338. https://doi.org/10.1007/s00415-009-0149-2

[5] Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia, 2013. 33: 629-808. Available from: https://doi.org/10.1177/0333102413485658

[6] Alghadir AH, Anwer S (2018) Effects of vestibular rehabilitation in the management of a VM: a review. Front Neurol 9: 440. https://doi.org/10.3389/fneur.2018.00440

[7] Lempert T, Olesen J, Furman J, et al. (2021) Vestibular migraine: diagnostic criteria (Update)¹. J Vestibul Res 32: 1-6. https://doi.org/10.3233/ves-201644

[8] Langhagen T, Lehrer N, Borggraefe I, et al. (2015) VM in children and adolescents: clinical findings and laboratory tests. Front Neurol 5: 292. https://doi.org/10.3389/fneur.2014.00292

[9] Dieterich M, Staab JP, Brandt T (2016) Functional (psychogenic) dizziness, Handbook of Clinical Neurology, 447-468, https://doi.org/10.1016/B978-0-12-801772-2.00037-0

[10] Luan S, Williams I, Nikolic K et al. (2014) Neuromodulation: present and emerging methods. Front Neuroeng 7: 27. https://doi.org/10.3389/fneng.2014.00027

[11] Staab JP, Rohe DE, Eggers SD, et al. (2014) Anxious, introverted personality traits in patients with chronic subjective dizziness. J Psychosom Res 76: 80-83. https://doi.org/10.1016/j.jpsychores.2013.11.008

[12] Othmer S, Othmer SF (2024) Endogenous neuromodulation at infra-low frequency: method and theory. Preprints. https://doi.org/10.20944/preprints202310.1085.v2

[13] Noda T, Nishikawa M, Matsuda Y, et al. (2025) Efficacy and safety of low-frequency repetitive transcranial magnetic stimulation for bipolar depression: a study protocol for a multicenter, double-blind, randomized, sham-controlled trial. Front Psychiatry 16: 1393605. https://doi.org/10.3389/fpsyt.2025.1393605

[14] Hallet M (2007) Transcranial magnetic stimulation: a primer. Neuron 55: 187199. https://doi.org/10.1016/j.neuron.2007.06.026

[15] Wassermann E, Epstein C, Ziemann U, et al. (2008) Oxford Handbook of Transcranial Stimulation. Oxford: Oxford University Press. https://doi.org/10.1093/oxfordhb/9780198568926.001.0001

[16] Cowey A (2004) The Ferrier Lecture 2004 What can transcranial magnetic stimulation tell us about how the brain works? Philosophical Transactions of the Royal Society B: Biological Sciences 360: 1185-1205. https://doi.org/10.1098/rstb.2005.1658

[17] Huerta PT, Volpe BT (2009) Transcranial magnetic stimulation, synaptic plasticity, and network oscillations. J Neuroeng Rehabil 6: 7. https://doi.org/10.1186/1743-0003-6-7

[18] Walsh V, Pascual-Leone A (2003) Transcranial Magnetic Stimulation: A Neurochronometrics of Mind. Cambridge: The MIT Press. https://doi.org/10.7551/mitpress/6896.001.0001

[19] Allen EA, Pasley BN, Duong T, et al. (2007) Transcranial magnetic stimulation elicits coupled neural and hemodynamic consequences. Science 317: 1918-1921. https://doi.org/10.1126/science.1146426

[20] Nitsche MA, Paulus W (2011) Transcranial direct current stimulation-update 2011. Restor Neurol Neurosci 29: 463492. https://doi.org/10.3233/rnn-2011-0618

[21] Thair H, Holloway AL, Newport R, et al. (2017) Transcranial direct current stimulation (tDCS): a beginner’s guide for design and implementation. Front Neurosci 11: 641. https://doi: 10.3389/fnins.2017.00641

[22] Fertonani A, Pirulli C, Miniussi C (2011) Random noise stimulation improves neuroplasticity in perceptual learning. J Neurosci 31: 15416-15423. https://doi.org/10.1523/jneurosci.2002-11.2011

[23] Berthelot N, Lemieux R, Garon Bissonnette J, et al. (2020) Uptrend in distress and psychiatric symptomatology in pregnant women during the coronavirus disease 2019 pandemic. Acta Obstet Gyn Scan 99: 848-855. https://doi.org/10.1111/aogs.13925

[24] Cui X, Bray S, Reiss AL (2009) Functional near-infrared spectroscopy (NIRS) signal improvement based on negative correlation between oxygenated and deoxygenated hemoglobin dynamics. NeuroImage 49: 3039-3046. https://doi.org/10.1016/j.neuroimage.2009.11.050

[25] Merzagora AC, Foffani G, Panyavin I, et al. (2010) Prefrontal hemodynamic changes produced by anodal direct current stimulation. NeuroImage 49: 2304-2310. https://doi.org/10.1016/j.neuroimage.2009.10.044

[26] Emre M, Aarsland D, Albanese A, et al. (2004) Rivastigmine for dementia associated with Parkinson’s disease. New Engl J Med 351: 2509-2518. https://doi.org/10.1056/nejmoa041470

[27] Stonsaovapak C, Hemrungroj S, Terachinda P, et al. (2020) Effect of anodal transcranial direct current stimulation at the right dorsolateral prefrontal cortex on the cognitive function in patients with mild cognitive impairment: a randomized double-blind controlled trial. Arch Phys Med Rehab 101: 1279-1287. https://doi.org/10.1016/j.apmr.2020.03.023

[28] Han BI, Song HS, Kim JS (2011) Vestibular rehabilitation therapy: review of indications, mechanisms, and key exercises. J Clin Neurol 7: 184. https://doi.org/10.3988/jcn.2011.7.4.184

[29] Cha YH, Cui Y, Baloh R, et al. (2013) Repetitive transcranial magnetic stimulation for mal de debarquement syndrome. Otol Neurotol 34: 175-179. https://doi.org/10.1097/mao.0b013e318278bf7c

[30] Tarnutzer AA, Ward BK, Shaikh AG, et al. (2023) Novel ways to modulate the vestibular system: Magnetic vestibular stimulation, deep brain stimulation, and transcranial magnetic stimulation / transcranial direct current stimulation. J Neurol Sci 445: 120544. https://doi.org/10.1016/j.jns.2023.120544

[31] Koganemaru S, Goto F, Arai M et al. (2017) Effects of vestibular rehabilitation combined with transcranial cerebellar direct current stimulation in patients with chronic dizziness: an exploratory study. Brain Stimul 10: 576-578. https://doi.org/10.1016/j.brs.2017.02.005

[32] Paxman E, Stilling J, Mercier L, et al. (2018) Repetitive transcranial magnetic stimulation (rTMS) as a treatment for chronic dizziness following mild traumatic brain injury. BMJ Case Rep 2018: 226698. https://doi.org/10.1136/bcr-2018-226698

[33] Moussavi Z, Suleiman A, Rutherford G, et al. (2019) A pilot randomised double-blind study of the tolerability and efficacy of repetitive transcranial magnetic stimulation on persistent post-concussion syndrome. Sci Rep 9: 5498. https://doi.org/10.1038/s41598-019-41923-6

[34] Buard I, Lopez-Esquibel N, Schoeneberger S, et al. (2020) Transcranial magnetic stimulation as treatment for mal de debarquement syndrome: case report and literature review. Cogn Behav Neurol 33: 145-153. https://doi.org/10.1097/wnn.0000000000000224

[35] Saki N, Bayat A, Nikakhlagh S, et al. (2022) Vestibular rehabilitation therapy in combination with transcranial direct current stimulation (tDCS) for treatment of chronic vestibular dysfunction in the elderly: a double-blind randomized controlled trial. Braz J Otorhinolar 88: 758-766. https://doi.org/10.1016/j.bjorl.2020.11.004

[36] Maertens de Noordhout A, Pepin JL, Schoenen J, et al. (1992) Percutaneous magnetic stimulation of the motor cortex in migraine. Electroencephalography and Clinical Neurophysiology/Evoked Potentials Section 85: 110-115. https://doi.org/10.1016/0168-5597(92)90076-n

[37] Bettucci D, Cantello R, Gianelli M, et al. (1922) Menstrual migraine without aura: cortical excitability to magnetic stimulation. J Head Face Pain 32: 345-347. https://doi.org/10.1111/j.1526-4610.1992.hed3207345.x

[38] Van Der Kamp W, Van Den Brink AM (1996) Interictal cortical hyperexcitability in migraine patients demonstrated with transcranial magnetic stimulation. J Neurol Sci 139: 106-110. https://doi.org/10.1016/s0022-510x(96)00044-5

[39] Brighina F, Piazza A, Vitello G, et al. (2004) rTMS of the prefrontal cortex in the treatment of chronic migraine: a pilot study. J Neurol Sci 227: 67-71. https://doi.org/10.1016/j.jns.2004.08.008

[40] Brighina F, Palermo A, Fierro B (2009) Cortical inhibition and habituation to evoked potentials: relevance for pathophysiology of migraine. J Headache Pain 10: 77-84. https://doi.org/10.1007/s10194-008-0095-x

[41] Cosentino G, Fierro B, Vigneri S, et al. (2014) Cyclical changes of cortical excitability and metaplasticity in migraine: evidence from a repetitive transcranial magnetic stimulation study. Pain 155: 1070-1078. https://doi.org/10.1016/j.pain.2014.02.024

[42] Afra J, Proietti Cecchini A, Sándor PS, et al. (2000) Comparison of visual and auditory evoked cortical potentials in migraine patients between attacks. Clin Neurophysiol 111: 1124-1129. https://doi.org/10.1016/s1388-2457(00)00271-6

[43] Gerwig M, Kastrup O, Meyer BU, et. al. (2003) Evaluation of cortical excitability by motor and phosphene thresholds in transcranial magnetic stimulation. J Neurol Sci 215: 75-78. https://doi.org/10.1016/s0022-510x(03)00228-4

[44] Young WB, Oshinsky ML, Shechter, et. al. (2004) Consecutive transcranial magnetic stimulation: phosphene thresholds in migraineurs and controls. J Head Face Pain 44: 131-135. https://doi.org/10.1111/j.1526-4610.2004.04028.x

[45] Chadaide Z, Arlt S, Antal A, et al. (2007) Transcranial direct current stimulation reveals inhibitory deficiency in migraine. Cephalalgia 27: 833-839. https://doi.org/10.1111/j.1468-2982.2007.01337.x

[46] Zeugin D, Ionta S (2021). Anatomo-functional origins of the cortical silent period: spotlight on the basal ganglia. Brain Sci 11: 705. https://doi.org/10.3390/brainsci11060705

[47] Paci M, Di Cosmo G, Perrucci MG, et al (2021) Cortical silent period reflects individual differences in action-stopping performance. Sci Rep 11: 15158. https://doi.org/10.1038/s41598-021-94494-w

[48] Aurora SK, al-Sayeed F, Welch KM, et al. (1999) The cortical silent period is shortened in migraine with aura. Cephalalgia 19: 708-712. https://doi.org/10.1046/j.1468-2982.1999.019008708.x

[49] Bohotin V, Fumal A, Vandenheede M, et al (2002) Effects of repetitive transcranial magnetic stimulation on visual evoked potentials in migraine. Brain 125: 912-922. https://doi.org/10.1093/brain/awf081

[50] Yuksel H, Topalkara KK (2021) Increased cortical excitability in female migraineurs: a transcranial magnetic stimulation study conducted in the preovulatory phase. J Clin Neurol 17: 236. https://doi.org/10.3988/jcn.2021.17.2.236

[51] Lan L, Zhang X, Li X, et al. (2017) The efficacy of transcranial magnetic stimulation on migraine: a meta-analysis of randomized controlled trials. J Headache Pain 18: 86. https://doi.org/10.1186/s10194-017-0792-4

[52] Narmashiri A, Akbari F (2023) The effects of transcranial direct current stimulation (TDCS) on the cognitive functions: a systematic review and meta-analysis. Neuropsychol Rev 35: 126-152. https://doi.org/10.1007/s11065-023-09627-x

[53] Teepker M, Hötzel J, Timmesfeld N, et al. (2010) Low-frequency rTMS of the vertex in the prophylactic treatment of migraine. Cephalalgia 30: 137-144. https://doi.org/10.1111/j.1468-2982.2009.01911.x

[54] Misra UK, Kalita J, Bhoi SK, et al. (2013) High-rate repetitive transcranial magnetic stimulation in migraine prophylaxis: a randomized, placebo-controlled study. J Neurol 260: 2793-2801. https://doi.org/10.1007/s00415-013-7072-2

[55] Hammad AB, Elsharkawy RE, Abdel Azim GS, et al. (2021) Repetitive transcranial magnetic stimulation as a prophylactic treatment in migraine. Egypt J Neurol Psychiatry Neurosurg 57: 5. https://doi.org/10.1186/s41983-020-00254-4

[56] Brighina F, Giglia G, Scalia S, et al. (2005) Facilitatory effects of 1 Hz rTMS in the motor cortex of patients affected by migraine with aura. Exp Brain Res 161: 34-38. https://doi.org/10.1007/s00221-004-2042-7

[57] Molgat CV, Patten SB (2005) Comorbidity of major depression and migraine-A Canadian population-based study. Can J Psychiat 50: 832-837. https://doi.org/10.1177/070674370505001305

[58] Dussor G (2019) Discoveries in migraine mechanisms and therapeutic targets. Curr Opin Physiol 11: 116-124. https://doi.org/10.1016/j.cophys.2019.10.013

[59] Borsook D, Maleki N, Becerra L, et al. (2012) Understanding migraine through the lens of maladaptive stress responses: a model disease of allostatic load. Neuron 73: 219-234. https://doi.org/10.1016/j.neuron.2012.01.001

[60] Carboni L, Khoury AE, Beiderbeck D (2022) Neuropeptide Y, calcitonin gene-related peptide, and neurokinin a in brain regions of HAB rats correlate with anxiety-like behaviours. Eur Neuropsychopharm 57: 1-14. https://doi.org/10.1016/j.euroneuro.2021.12.011

[61] Kauppila E, Vanninen E, Kaurijoki S, et al. (2013) Influence of serotonin transporter gene polymorphism (5-HTTLPR Polymorphism) on the relation between brain 5-HT transporter binding and heart rate-corrected cardiac repolarization interval. Plos One 8: e50303. https://doi.org/10.1371/journal.pone.0050303

[62] Furman JM, Marcus DA, Balaban CD (2013) VM: clinical aspects and pathophysiology. Lancet Neurol 12: 706-715. https://doi.org/10.1016/s1474-4422(13)70107-8

[63] Pistoia F, Salfi F, Saporito G, et al. (2022) Behavioral and psychological factors in individuals with migraine without psychiatric comorbidities. J Headache Pain 23: 110. https://doi.org/10.1186/s10194-022-01485-x

[64] Powers SW, Kashikar-Zuck SM, et al. (2013) Cognitive behavioral therapy plus amitriptyline for chronic migraine in children and adolescents. JAMA 310: 2622. https://doi.org/10.1001/jama.2013.282533

[65] Bottiroli S, De Icco R, Vaghi G, et al. (2021) Psychological predictors of negative treatment outcome with Erenumab in chronic migraine: data from an open-label long-term prospective study. J Headache Pain 22: 114. https://doi.org/10.1186/s10194-021-01333-4

[66] Schwartz WJ, Klerman EB (2019) Circadian neurobiology and the physiologic regulation of sleep and wakefulness. Neurol Clin 37: 475-486. https://doi.org/10.1016/j.ncl.2019.03.001

[67] Hastings MH, Maywood ES, Brancaccio M, et al. (2018) Generation of circadian rhythms in the suprachiasmatic nucleus. Nat Rev Neurosci 19: 453. https://doi.org/10.1038/s41583-018-0026-z

[68] Stokes DA, Lappin MS (2010) Neurofeedback and biofeedback with 37 migraineurs: a clinical outcome study. Behav Brain Funct 6: 9. https://doi.org/10.1186/1744-9081-6-9

[69] Legarda SB, Michas-Martin PA, McDermott D (2022) Remediating intractable headache: an effective nonpharmacological approach employing infralow frequency neuromodulation. Front Hum Neurosci 16: 894856. https://doi.org/10.3389/fnhum.2022.894856

[70] Sasu R (2022) Infra-low frequency neurofeedback in persistent postural-perceptual dizziness-Case report. Front Hum Neurosci 16: 959579. https://doi.org/10.3389/fnhum.2022.959579

[71] Arina M, Zhao H, Rasgado-Toledo J (2022) Infralow neurofeedback for tension-type headache: a randomized, crossover sham-controlled study. Front Human Neurosci 16: 891323. https://doi.org/10.3389/fnhum.2022.891323

[72] Kirsch V, Keeser D, Hergenroeder T, et al. (2016) Structural and functional connectivity mapping of the vestibular circuitry from human brainstem to cortex. Brain Struct Funct 221: 1291-1308. https://doi.org/10.1007/s00429-014-0971-x

[73] Young A, Cornejo J, Spinner A (2023) Auditory brainstem response.

[74] Yamada T, Dickins QS, Arensdorf K, et al. (1986) Basilar migraine: polarity-dependent alteration of brainstem auditory evoked potential. Neurology 36: 1256-1260. https://doi.org/10.1212/wnl.36.9.1256

[75] Yoo H, Mihaila DM (2022) Neuroanatomy, vestibular pathways.

[76] Ricci A, Rubino E, Pietro Serra G, et al. (2024) Concerning neuromodulation as treatment of neurological and neuropsychiatric disorders: insights gained from selective targeting of the subthalamic nucleus, para-subthalamic nucleus, and zona incerta in rodents. Neuropharmacology 256: 110003. https://doi.org/10.1016/j.neuropharm.2024.110003

[77] Walsh GS (2021) Dynamics of modular neuromotor control of walking and running during single and dual task conditions. Neuroscience 465: 1-10. https://doi.org/10.1016/j.neuroscience.2021.04.004

[78] Taslim S, Shadmani S, Saleem A, et al. (2024) Neuropsychiatric disorders: bridging the gap between neurology and psychiatry. Cureus 16: e51655. https://doi.org/10.7759/cureus.51655

[79] Fletcher JL, Murray SS, Xiao J (2018) Brain-derived neurotrophic factor in central nervous system myelination: a new mechanism to promote myelin plasticity and repair. Int J Mol Sci 19: 4131. https://doi.org/10.3390/ijms19124131

[80] Fischer M, Wille G, Klien S, et al. (2012) Brain-derived neurotrophic factor in primary headaches. J Headache Pain 13: 469-475. https://doi.org/10.1007/s10194-012-0454-5

[81] Bliss TV, Cooke SF (2011) Long-term potentiation and long-term depression: a clinical perspective. Clinics 66: 3-17. https://doi.org/10.1590/s1807-59322011001300002

[82] Meldrum BS (2000) Glutamate as a neurotransmitter in the brain: review of physiology and pathology. J Nutr 130: 1007S-1015S. https://doi.org/10.1093/jn/130.4.1007s

[83] Jewett BE, Thapa B (2022) Physiology, NMDA receptor.

[84] Blanke ML, VanDongen AM (2009) Activation mechanisms of the NMDA receptor.

[85] Chervyakov AV, Chernyavsky AY, Sinitsyn DO, et. al. (2015) Possible mechanisms underlying the therapeutic effects of transcranial magnetic stimulation. Front Human Neurosci 9: 303. https://doi.org/10.3389/fnhum.2015.00303

[86] Wu X, Han S, Yang Y, et al. (2022) Decreased brain GABA levels in patients with migraine without aura: an exploratory proton magnetic resonance spectroscopy study. Neuroscience 488: 10-19. https://doi.org/10.1016/j.neuroscience.2022.02.010

[87] Tremblay R., Lee S, Rudy B (2016) GABAergic interneurons in the neocortex: from cellular properties to circuits. Neuron 91: 260-292. https://doi.org/10.1016/j.neuron.2016.06.033

[88] Caparelli E, Backus W, Telang F, et al. (2012). Is 1 Hz RTMS always inhibitory in healthy individuals?. Open Neuroimag J 6: 69-74. https://doi.org/10.2174/1874440001206010069

[89] Phylactou P, Pham T, Narskhani N, et al. (2024) Phosphene and motor transcranial magnetic stimulation thresholds are correlated: a meta-analytic investigation. Prog Neuro-Psychoph 133: 111020. https://doi.org/10.1016/j.pnpbp.2024.111020

[90] Zuniga SA, Adams ME (2021) Efficient use of vestibular testing. Otolaryng Clin N Am 54: 875-891. https://doi.org/10.1016/j.otc.2021.05.011

[91] Peterchev AV, Murphy DL, Goetz SM (2015) Quiet transcranial magnetic stimulation: status and future directions. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society, 226-229. https://doi.org/10.1109/EMBC.2015.7318341

[92] Rossi S, Antal A, Bestmann S, et al. (2021) Safety and recommendations for TMS use in healthy subjects and patient populations, with updates on training, ethical and regulatory issues: expert guidelines. Clin Neurophysiol 132: 269-306. https://doi.org/10.1016/j.clinph.2020.10.003

[93] Matsumoto H, Ugawa Y (2016) Adverse events of tDCS and tACS: a review. Clin Neurophys Pract 2: 19-25. https://doi.org/10.1016/j.cnp.2016.12.003

[94] Magnezi R, Aminov E (2016) Comparison between neurostimulation techniques, repetitive transcranial magnetic stimulation vs electroconvulsive therapy for the treatment of resistant depression: patient preference and cost-effectiveness. Patient Prefer Adher 10: 1481-1487. https://doi.org/10.2147/PPA.S105654

[95] Xia Y, Xu Y, Li Y, et al. (2022) Comparative efficacy of different repetitive transcranial magnetic stimulation protocols for stroke: a network meta-analysis. Front Neurol 13: 918786. https://doi.org/10.3389/fneur.2022.918786