Introduction
While immersive virtual reality (VR) technology has seen widespread adoption across entertainment, educational, and training domains, its concomitant neurological and physiological effects remain inadequately characterized. A growing body of literature indicates that VR immersion can elicit a constellation of adverse symptoms, including headache, dizziness, disorientation, nausea, visual strain, and general discomfort. This symptom cluster is formally categorized as VR‐induced symptoms and effects (VRISE), a phenomenon colloquially known as cybersickness [1].
Some studies suggest that even short VR sessions can trigger symptoms in a substantial proportion of users, with up to 80% experiencing discomfort after just 10 min of immersion. This highlights the high prevalence of VRISE, as many users develop symptoms even after brief exposure [2]. Although VR‐induced discomfort and headache have been documented, the impact of VR exposure on the postdromal phase of migraines, particularly in cases involving brainstem aura, is less explored.
The postdromal phase typically resolves within hours to a day, characterized by fatigue and mild cognitive difficulties. However, in rare cases, symptoms can persist for longer, which can impair daily functioning [3]. This report describes a migraine with brainstem aura–like presentation with prolonged symptoms following immersive VR exposure, highlighting a possible relationship between immersive sensory stimulation and migraine‐related neurological symptoms.
Case Presentation
A 32‐year‐old male developed sudden neurological symptoms immediately after completing a 30‐min immersive virtual reality gaming session. Upon removing the headset, he initially experienced dizziness and mild vertigo, followed by subjective sensory reduction involving the face and both hands. During the same episode, he also reported marked cognitive clouding, disorientation, and a sensation of derealization.
The symptoms persisted throughout the remainder of the day, with partial subjective improvement by the evening.
The following day, the patient entered a crowded shopping mall with bright lighting and ambient noise. Within approximately 1–2 min of exposure to this multisensory environment, the sensory disturbance became more pronounced and the overall symptoms worsened. This exacerbation persisted until the following day.
Approximately, 3 days after the initial VR exposure, the patient presented to the hospital, where otolaryngological, neurological, and cognitive evaluations were performed on the same day.
During the subsequent 2 weeks, the patient continued to experience fluctuating neurological and cognitive symptoms, including persistent cognitive fatigue, impaired concentration, difficulty following conversations, subjective reduction in facial and bilateral hand sensation, positional dizziness that was more noticeable while supine, hypersomnia of up to approximately 12 h per night despite nonrestorative sleep, unusually frequent vivid dreams, and intermittent pressure‐like, cap‐like headaches occurring approximately every 48 h. He also reported visual difficulty in low‐light conditions and with color differentiation. Throughout the clinical course, he denied motor weakness, visual loss, diplopia, dysarthria, or loss of consciousness.
The patient had no prior personal history of primary headache disorders but reported a significant family history of migraine with aura in a first‐degree relative. The presentation demonstrated brainstem aura–like features, particularly fully reversible vertigo without motor symptoms. However, only one definite brainstem symptom recognized by the International Classification of Headache Disorders, 3rd edition (ICHD‐3) was documented, and this represented a single clinical episode.
Therefore, the presentation did not fulfill ICHD‐3 criteria for definite migraine with brainstem aura and was considered a migraine with brainstem aura–like presentation. Symptoms gradually improved over approximately 2 weeks, with complete recovery and return to his premorbid neurological status.
Investigation, Differential Diagnosis, and Treatment
Initial otolaryngological evaluation, including pure‐tone audiometry and external ear examination, was unremarkable. Comprehensive neurological examination revealed intact cranial nerves, including symmetric extraocular movements without nystagmus or diplopia. Pupillary light reflex, motor function, gait, coordination, and reflexes were all normal.
Fundoscopic examination showed no papilledema or other abnormalities. Although the patient reported subjective hypoesthesia involving the face and bilateral hands, no corresponding objective sensory deficit was identified. Cognitive screening with the Montreal Cognitive Assessment (MoCA) revealed no significant impairment.
No laboratory investigations or electrocardiography were performed.
The chronological evolution of the clinical course is summarized in Figure 1. The clinical presentation was considered a migraine with brainstem aura–like presentation rather than definite migraine with brainstem aura according to ICHD‐3 criteria. Neuroimaging was not performed; therefore, structural and vascular causes could not be definitively excluded.
The management approach was primarily symptomatic. The patient was prescribed verapamil sustained‐release 240 mg once daily and lorazepam 1 mg once daily for 7 days as short‐term symptomatic management during recovery rather than as long‐term treatment. Ibuprofen 400 mg was prescribed as needed for headache relief.
The medications were limited to 1 week because they were intended to provide temporary symptomatic relief while the episode gradually resolved.
Outcome and Follow‐Up
In addition to pharmacological management, behavioral interventions were strongly emphasized. The patient was advised to avoid sensory stimuli, especially immersive VR environments and visually complex settings, as these could exacerbate the ongoing symptoms. The patient was also encouraged to maintain a regular sleep schedule and engage in light physical activities, as tolerated, to support recovery.
Over the course of 2 weeks, the patient's symptoms gradually improved, culminating in a full recovery with return to his premorbid neurological status and no residual deficits. At the 3‐ and 6‐month follow‐ups, he remained symptom‐free without recurrent vertigo, cognitive symptoms, sensory disturbances, or other similar neurological episodes.
Discussion
This case describes prolonged neurological symptoms lasting approximately 2 weeks after a migraine with brainstem aura–like presentation that occurred immediately following immersive virtual reality (VR) exposure. In most migraine attacks, the postdromal phase resolves within hours to one day. Large cohort studies demonstrate that approximately 88% of patients return to baseline within 24 h of headache resolution [4].
The average postdromal duration is ~25 h, with only a small minority experiencing symptoms beyond 1–2 days [3, 4]. Persistence of neurological symptoms for approximately 2 weeks is substantially longer than the typical migraine postdrome, underscoring the unusual duration of this episode, as illustrated by the clinical timeline in Figure 1. Notably, migraine with brainstem aura (MBA), previously termed basilar‐type migraine, is a rare subtype of migraine.
It accounts for approximately 1.5% of all headache disorders and represents between 6.6% and 10% of migraines accompanied by aura [5], characterized by transient brainstem symptoms (e.g., vertigo, dysarthria, diplopia, tinnitus, ataxia, decreased consciousness) without motor weakness [6]. Although the patient exhibited vertigo together with acute disorientation and cognitive clouding, the latter symptoms were not considered equivalent to the ICHD‐3 criterion of decreased level of consciousness. Accordingly, only one definite brainstem symptom recognized by ICHD‐3 was documented.
In addition, this represented a single clinical episode. The case therefore does not fulfill ICHD‐3 criteria for definite migraine with brainstem aura and is described more cautiously as a migraine with brainstem aura–like presentation [7]. Although the acute presentation may resemble serious secondary neurological conditions, the absence of persistent focal deficits, papilledema, or progressive deterioration, together with complete recovery, was clinically compatible with a migraine‐spectrum presentation; however, the available findings were insufficient to establish definite migraine with brainstem aura.
The differential diagnosis included transient ischemic attack or another posterior circulation process, vestibular neuritis, and VR‐induced symptoms and effects (VRISE), including cybersickness. A vascular cause was considered clinically less typical because of the prolonged and fluctuating course without persistent focal neurological deficits; however, it could not be definitively excluded because neuroimaging was not performed. Vestibular neuritis was considered less likely because there was no persistent spontaneous nystagmus or continuous acute vestibular syndrome, and the presentation included prominent cognitive and sensory symptoms [8].
Cybersickness was also considered because immersive VR can produce dizziness, disorientation, visual discomfort, and headache, which overlap substantially with the symptoms observed in this case.
Cybersickness was an important competing explanation because immersive VR can produce dizziness, disorientation, visual discomfort, nausea, and headache through visual–vestibular sensory conflict [9]. These symptoms overlap substantially with migraine‐related manifestations and can occur during or shortly after VR exposure [9, 10].
In this case, the prolonged cognitive fatigue, sensory complaints, hypersomnia, recurrent worsening with multisensory stimulation, and approximately two‐week recovery period were considered more suggestive of a migraine‐spectrum neurological response than uncomplicated transient cybersickness alone. However, because cybersickness and migraine‐related symptoms overlap and no specific diagnostic test distinguishes the two in this setting, cybersickness could not be definitively excluded. The presentation is therefore described cautiously as migraine with brainstem aura–like rather than definite migraine with brainstem aura [7, 10, 11].
Migraine is increasingly understood as a disorder involving altered sensory network processing rather than solely a pain condition. Individuals with migraine exhibit hypersensitivity to sensory stimuli including visual, auditory, and somatosensory inputs even between attacks, reflecting atypical sensory processing and incomplete normalization of neural networks. This persistent hypersensitivity provides a biologically plausible explanation for the recurrence or persistence of symptoms in this patient when exposed to visually complex and noisy environments during the recovery period [11, 12].
Several limitations should be acknowledged. Neuroimaging was not performed, preventing definitive radiological exclusion of structural or vascular causes. In addition, the temporal relationship between immersive VR exposure and symptom onset does not establish causality, and the possibility of a coincidental migraine‐spectrum event cannot be excluded.
Because this was a single clinical episode without VR re‐exposure, VR cannot be considered a confirmed or reproducible trigger.
From a clinical perspective, this case highlights prolonged neurological symptoms occurring in close temporal association with immersive VR exposure and subsequent multisensory overstimulation. Recognition of recent VR exposure may provide useful clinical context when evaluating similar presentations. Further studies are needed to clarify the relationship between immersive VR exposure, cybersickness, and migraine‐spectrum symptoms.
The reporting of this study conforms to the Case Report (CARE) guidelines [13].
Conclusion
This case describes a migraine with brainstem aura–like presentation with prolonged neurological symptoms occurring shortly after immersive virtual reality exposure. Recent VR exposure may provide useful clinical context when evaluating similar presentations. In this patient, symptoms resolved with time, symptomatic management, and avoidance of provocative sensory exposures.
Further study is needed to clarify the relationship between immersive VR exposure, cybersickness, and migraine‐spectrum symptoms.
Author Contributions
Abdulrahman Al‐Dawoudi: writing – original draft, methodology, visualization, writing – review and editing. Daniil Varlamov: writing – review and editing, validation. Shaghaf Alhallak: writing – review and editing, visualization.
Mujahed Dalain: writing – review and editing, supervision, validation, project administration.
Funding
The authors have nothing to report.
Ethics Statement
This study was conducted in accordance with the Declaration of Helsinki and the guidelines of the journal.
Consent
Written informed consent was obtained from the patient for publication of this case report.
Conflicts of Interest
The authors declare no conflicts of interest.