06/16/2026
This is such a good clinical question and the answer is more straightforward than you might think.
As PTs and OTs, it is worth clarifying what “ruling in or out” means for us. We are not confirming or excluding a medical diagnosis. We are doing what we always do —> identifying the deficits we can address, educating our patient, and getting them to the right medical provider when the clinical picture calls for it.
That starts with a thorough vestibular evaluation. Full oculomotor exam, balance testing, and positional testing. Every time. Finding another vestibular disorder does not rule vestibular migraine out, and an unremarkable exam does not either. It all becomes part of the clinical picture you are building.
If you are specifically suspicious of vestibular migraine, there are some additional tools worth adding to your evaluation:
1. VM-PATHI is a validated patient reported outcome measure specific to vestibular migraine. It has shown the ability to detect measurable change with VM treatment, including physical therapy, which makes it a useful tool for tracking progress over time.
2. Modified Motion Sensitivity Test is useful when your patient reports that movement triggers or worsens their symptoms. (shoutout to Lisa Gillig for developing this wonderful tool!)
3. Bucket Test is worth adding if you are suspicious of otolith hypersensitivity, which can be a feature of VM. (Hint: do this if they say the world feels tilted or they are sensitive to linear movements - I.e. elevator)
4. Visual Vertigo Analog Scale is helpful when your patient reports that busy visual environments, scrolling, or moving objects make their symptoms worse.
The evaluation is not as different as you might expect. What changes is knowing which add-ons to use and understanding that your findings, whatever they are, help point your patient toward the right care.
