Conference Coverage

Intravenous Nitroglycerin Provoked Headache, Vestibular Symptoms Without Consistent Nystagmus Changes

Edited by:
Anthony Calabro, MA

Key Highlights

  • Intravenous nitroglycerin provoked headache in all 20 participants with definite vestibular migraine.
  • Vestibular symptoms occurred in 13 of 20 participants after nitroglycerin provocation.
  • Quantitative slow-phase velocity measures of nystagmus did not show a statistically significant group-level change across baseline, nitroglycerin, and post-sumatriptan conditions.
  • The researchers suggested that vestibular migraine episodes may be partially explained by reduced vestibular thresholds, leading to vestibular hypersensitivity.

Nitroglycerin reliably provoked headache and vestibular symptoms in participants with vestibular migraine, but it did not produce consistent group-level changes in nystagmus, according to findings from an Early Career Lecture Award presentation at the American Headache Society 68th Annual Scientific Meeting in Orlando, FL. The study, “Visual, Vestibular, and Ocular Motor Changes During Nitroglycerin-triggered Vestibular Migraine,” was presented by Maria Dolores Villar-Martinez, MD, of King’s College London.

In their study, the researchers noted that intravenous nitroglycerin is a well-established model for provoking migraine attacks, but it had not previously been used to characterize vestibular migraine. Since different types of nystagmus have been observed during spontaneous vestibular migraine attacks, the investigators aimed to measure nystagmus changes during nitroglycerin-induced migraine in participants with vestibular migraine.

The study included 20 participants with definite vestibular migraine, according to Bárány–ICHD-3 criteria, who underwent nitroglycerin provocation at King’s College Hospital in London. Participants had a mean age of 33 years (SD, 8), and 16 of 20 were women.

Researchers used three-dimensional video-oculography to quantify total slow-phase velocity (SPV) of nystagmus without fixation in center, left, right, up, and down positions. Recordings were performed before nitroglycerin, after nitroglycerin, and after subcutaneous sumatriptan. Subjective vestibular symptoms and headache intensity were measured using a numeric scale, and longitudinal changes in SPV were analyzed using negative binomial mixed-effects models.

Study Findings

All participants developed headaches after nitroglycerin provocation. Median peak headache severity was 6/10, with an interquartile range of 3. Vestibular symptoms were triggered in 13 of 20 participants after nitroglycerin, with a median maximum intensity of 1.5 and an interquartile range of 4.

Median total SPV was 2 at baseline (interquartile range: 2), 2 during nitroglycerin exposure (interquartile range: 5.5), and 1 after sumatriptan (interquartile range: 4.25). The researchers reported no statistically significant group-level change in total SPV across conditions.

Nitroglycerin provocation was also associated with complex perceptions in some participants. Visual aura occurred in 9 of 20 participants, derealization or depersonalization in 5 of 20, and metamorphopsia in 3 of 20. These findings are from the study presented here and should not be extrapolated beyond the reported vestibular migraine cohort.

Clinical Implications

According to the study authors, quantitative SPV measures of nystagmus did not show a uniform group-level change during nitroglycerin provocation in vestibular migraine, despite frequent subjective vestibular symptoms. They suggested that vestibular migraine episodes may be partially explained by a reduction in vestibular thresholds leading to vestibular hypersensitivity.

Expert Commentary

“Quantitative SPV measures of nystagmus did not show a uniform group-level change during NTG provocation in VM, despite frequent subjective vestibular symptoms. VM episodes may be partially explained by a reduction in vestibular thresholds leading to vestibular hypersensitivity,” the researchers concluded.

Reference
Villar-Martinez MD, Bronstein AM, Domingos-Belo C, Puledda F, Goadsby P. Early Career Lecture Award: visual, vestibular, and ocular motor changes during nitroglycerin-triggered vestibular migraine. Presented at: 68th Annual Scientific Meeting of the American Headache Society; June 5, 2026; Orlando, FL.