• Valerie Kirsch, Rainer Boegle, Johannes Gerb, Emilie Kierig, Birgit B Ertl-Wagner, Sandra Becker-Bense, Thomas Brandt, and Marianne Dieterich.
• German Center for Vertigo and Balance Disorders, Ludwig-Maximilians-University, Munich, Germany.
• J. Neurol. Neurosurg. Psychiatr. 2024 Sep 13.

BackgroundVestibular migraine (VM), the most frequent episodic vertigo, is difficult to distinguish from Ménière's disease (MD) because reliable biomarkers are missing. The classical proof of MD was an endolymphatic hydrops (EH). However, a few intravenous gadolinium-enhanced MRI studies of the inner ear (iMRI) also revealed an EH in VM. The major questions were the frequency and distribution characteristics of EH in VM for diagnostic use.MethodsIn a prospective case-control study of 200 participants, 75 patients with VM (49 females; mean age 46 years) and 75 with MD (36 females; mean age 55 years), according to the Bárány and International Headache Society, and 50 age-matched participants with normal vestibulocochlear testing (HP), were enrolled. Analyses of iMRI of the endolymphatic space included volumetric quantification, stepwise regression, correlation with neurotological parameters and support vector machine classification.ResultsEH was maximal in MD (80%), less in VM (32%) and minimal in HP (22%). EH was milder in VM (mean grade 0.3) compared with MD (mean grade 1.3). The intralabyrinthine distribution was preferably found in the vestibulum in VM, but mainly in the cochlea in MD. There was no interaural lateralisation of EH in VM but in the affected ear in MD. The grade of EH in the vestibulum was correlated in both conditions with the frequency and duration of the attacks.ConclusionThree features of the iMRI evaluation were most supportive for the diagnosis of VM at group and individual levels: (1) the bilateral manifestation, (2) the low-grade EH and (3) the intraaural distribution.© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

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