# Virtual reality–based assessment of visuo-vestibular integration in vestibular migraine and migraine: static and dynamic visual vertical and rod-and-frame tests

## TL;DR

This study uses virtual reality to assess balance and visual perception in people with vestibular migraine and migraine, finding that dynamic tests better reflect their daily challenges.

## Contribution

A novel VR-based protocol combining static and dynamic visuo-vestibular tests for evaluating vestibular migraine.

## Key findings

- VM patients showed greater SVV and DSVV deviations compared to healthy controls.
- RFT revealed strong visual dependence in VM patients, with significant group differences.
- DSVV and RFT scores correlated more strongly with disability than static SVV.

## Abstract

Vestibular migraine (VM) is the most common cause of episodic vertigo, yet its diagnostic markers remain limited. Perception of verticality, measured via static subjective visual vertical (SVV), dynamic SVV (DSVV), and the rod-and-frame test (RFT), provides insight into visuo-vestibular integration. Traditional approaches, however, often test these paradigms in isolation with limited ecological validity.

To evaluate a novel virtual reality (VR)-based protocol combining SVV, DSVV, and RFT to characterize visuo-vestibular integration in VM, migraine without vestibular symptoms (M), and healthy controls (HC).

Fifty participants (VM n = 15, M n = 15, HC n = 20) completed VR-based SVV, DSVV, and RFT assessments using the BalanceVR system. Disability was assessed using the Dizziness Handicap Inventory (DHI) and Migraine Disability Assessment (MIDAS). Between-group differences were analyzed using Kruskal–Wallis tests with Mann–Whitney U post-hoc comparisons. Correlations between orientation measures and questionnaires were assessed using Spearman’s rho.

VM patients exhibited significantly greater SVV deviations than HC (p = 0.015). DSVV errors were elevated in VM vs. HC (p = 0.040). RFT showed robust group differences (p < 0.001), with the most significant visual dependence in VM. DHI and MIDAS scores were significantly higher in both patient groups than HC (p < 0.001). DSVV (ρ ≈ 0.45) and RFT (ρ ≈ 0.69) showed stronger correlations with disability than static SVV (ρ ≈ 0.30).

VM is characterized by difficulties in dynamic and visually complex situations, rather than static balance problems. Combining DSVV and RFT with SVV enhances diagnostic sensitivity, explains patients’ daily challenges, and supports rehabilitation approaches aimed at reducing visual dependence and improving sensory balance.