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Journal of the American Academy of Audiology logoLink to Journal of the American Academy of Audiology
. 2026 Jan 1;37(1):34–41. doi: 10.3766/jaaa.250017

Cognitive Abilities and Listening Effort in Individuals with Vestibular Migraine

Vibha Vinod *,✉, Animesh Barman *
PMCID: PMC13086606  PMID: 40931563

Abstract

Background:

Given the evidence of cognitive deficits in individuals with vestibular dysfunction, reduced cognitive resources may impact the effort required to process auditory information, particularly in adverse listening conditions. Although existing literature suggests impaired performance on cognitive tasks in vestibular disorders in general, research in this area specific to patients with vestibular migraine is limited.

Purpose:

This article aims to investigate working memory, auditory attention, and listening effort among individuals with vestibular migraine.

Research Design:

This study employed a non-experimental standard group comparison design.

Study Sample:

Individuals with vestibular migraine (n = 14) and healthy control subjects (n = 13) were recruited.

Data Collection and Analysis:

Operation Span and Backward Digit Span tasks were administered to assess the working memory and test of attention in listening to assess auditory attention, and listening effort was assessed using the dual-task paradigm.

Results:

The Operation Span, Reaction Time for the attention task, and the Repeat and Recall scores for the listening effort task were significantly poorer in the vestibular migraine group than in the control group.

Conclusions:

These outcomes underscore the cognitive burden imposed by vestibular migraine and emphasize the need for further research to explore the underlying mechanisms and develop targeted interventions to address these deficits.

Clinical Relevance Statement:

This study emphasizes the clinical importance of early identification of vestibular migraine to mitigate its potential impact on cognitive and auditory functioning. It highlights the need for routine assessment of working memory, attention, and listening effort, enabling timely intervention through targeted rehabilitation strategies to improve patient outcomes.

Keywords: attention, working memory, listening effort, vertigo, cognition

INTRODUCTION

The vestibular system plays a critical role in maintaining postural stability. The sensory inputs, resulting from head movements in space, are transmitted to the vestibular nuclei, where they are integrated with information from other sensory modalities to calculate the gravito-inertial vector (Cohen et al., 2001; Imai et al., 2001). Vestibular neural projections extend to both the cerebellum and the cerebral cortex, facilitating motor coordination and balance. In addition, the vestibular apparatus is linked to the limbic system—which regulates emotions, memory formation, decision-making, and other higher cognitive functions—highlighting its broader influence beyond motor control (Efimova & Volkova, 2023; Guidetti & Guidetti, 2014; Ribeiro et al., 2023; Smith, 1997).

Disruption of vestibular function can alter the sensory information reaching these centers in the central nervous system (Guo et al., 2024), resulting in debilitating symptoms of loss of balance and vertigo, as well as emotional disturbance for the patient. As a result, additional cognitive resources are recruited to maintain balance and posture—typically an automated process—causing affected individuals to experience cognitive fatigue, disorientation, and confusion. This cognitive overload further impairs higher-order functions (Bigelow & Agrawal, 2015; Egeth, 1975).

Evidence from cognitive-vestibular research suggests that individuals with vestibular dysfunction show long-term deficits not only in spatial cognition but also in non-spatial cognitive tasks such as attention and working memory (Chari et al., 2022). For example, visuospatial working memory is notably impaired in individuals with bilateral vestibular loss, as demonstrated by poorer performance on the Corsi block tapping test compared with healthy controls (Guidetti et al., 2020). Danneels et al. (2023) reported that individuals with bilateral vestibular pathology had poor auditory and visual working memory. Ayar, Kumral, and Celebisoy (2020) reported forward digit span test performance to be similar for individuals with vestibular dysfunction compared with those in the healthy control group. However, the Backward Digit Span test was significantly lower in individuals with vestibular dysfunction. In contrast, Ahmad et al. (2022) found similar forward and Backward Digit Span performance for individuals with and without vestibular dysfunction. Electrophysiological findings support these behavioral observations, revealing that with increasing severity of vestibular symptoms, auditory P300 latencies are significantly prolonged with significantly reduced P300 amplitudes, suggesting greater impairment in auditory attention (Ma et al., 2023).

Vestibular migraine is a neurological disorder characterized by recurrent episodes of vestibular symptoms and migraine. According to Lempert et al. (2022), diagnosis requires at least five episodes of vertigo of moderate to severe intensity, each lasting between 5 minutes and 72 hours. Patients must have a current or previous history of migraine, with or without aura, as defined by the International Classification of Headache Disorders, 3rd edition (ICHD-3). During at least 50 percent of the episodes, one or more typical migraine features, such as pulsatile, unilateral headache of moderate to severe intensity, worsening with routine physical activities, photophobia, or phonophobia. Individuals with vestibular migraine have also demonstrated impaired memory function compared with individuals without vestibular migraine (Tawfik et al., 2021). In addition to its effects on balance and coordination, vestibular migraine may impact emotional and cognitive functions via its connections with cortical and subcortical brain regions. These abnormalities may increase the cognitive load required to maintain functional performance, thereby negatively affecting tasks that demand working memory and attention. However, research on these cognitive consequences remains limited.

Cognitive deficits associated with vestibular dysfunction, including those observed in vestibular migraine, may extend beyond spatial processing and memory. Listening effort refers to the attention, cognitive resources, and mental effort required to understand speech (Downs, 1982; Feuerstein, 1989; McGarrigle et al., 2014). Given the evidence of cognitive deficits in individuals with vestibular dysfunction, reduced cognitive resources may impact the effort required to process auditory information, particularly in adverse listening conditions. This suggests that vestibular dysfunction may not only affect balance and spatial cognition but also increase the perceptual effort needed for speech recognition. Notably, empirical evidence on the relationship between working memory, auditory attention, and listening effort in individuals with vestibular migraine is sparse.

Therefore, this study aims to compare working memory, auditory attention, and listening effort among individuals with vestibular migraine and healthy controls.

METHODS

This study employed a non-experimental, standard group comparison design. Participants aged 20 to 50 years were recruited through non-random purposive sampling and categorized into two groups: the control group (n = 13) comprising healthy individuals without vestibular migraine, and the vestibular migraine group (n = 14) comprising individuals diagnosed according to the diagnostic criteria outlined by Lempert et al. (2022). Diagnosis of vestibular migraine was made by an otologist. All participants in the vestibular migraine group were assessed within one week after an attack of vestibular migraine and were not on medication for the condition at the time of assessment. None of the participants had comorbid anxiety or depression as per screening using the Hamilton Depression Rating Scale and Hamilton Rating Scale for Anxiety (Hamilton, 1959, 1960).

Exclusion criteria included hearing impairment, middle ear pathology, any obvious cognitive impairment, and non-native proficiency in Kannada. Screening for these was conducted using pure-tone audiometry, tympanometry, and the Mini-Mental State Examination (Folstein et al., 1975). The demographic characteristics of both groups are given in Table 1. The study protocol was approved by the Institutional Review Board of the institute, and written informed consent was obtained before data collection.

Table 1.

Demographic Details of the Participants in the Vestibular Migraine and Control Groups

Characteristics Vestibular migraine (n = 14) Healthy control (n = 13)
Age, years (mean ± SD) 25.54 ± 4.40 35.14 ± 5.18
Gender (female/male) 10/3 9/5
Education level Secondary education to postgraduate Higher secondary education to postgraduate
Duration of migraine symptoms 6 months to 4 years not applicable
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The experiments were carried out in a quiet room free from external distractors. The cognitive assessment included measures of working memory (auditory Backward Digit Span and Operation Span), auditory attention (test of attention in listening), and listening effort (using a dual-task paradigm). These tests were selected based on their ability to tap into specific cognitive domains, aligning with the study objective (Table 2). All tasks were administered in Kannada.

Table 2.

Cognitive Domain of Each Test Used in the Study and the Theoretical Rationale for Selecting the Tests

Task Cognitive domain Theoretical rationale
Auditory Backward Digit Span Auditory working memory Assesses the capacity to temporarily store and manipulate auditory-verbal information; important for speech processing and mental tracking
Operation Span task Complex working memory (processing + storage) Measures the ability to manage dual demands of processing and storage, reflecting real-world cognitive multitasking
Reaction Time task Processing speed and sustained attention Captures speed of sensory processing and consistency of attentional engagement, both of which may be affected by vestibular dysfunction and cognitive fatigue
Listening effort task Auditory attention and cognitive load Evaluates the mental effort required to perceive and recall speech, particularly under challenging listening conditions—critical for understanding speech-in-noise
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Working memory refers to the capacity to temporarily store and manipulate information for goal-directed behavior and complex cognitive tasks. It is typically measured using tasks that involve both storage and processing demands, such as the Operation Span task and the Backward Digit Span task, which require both storage and mental manipulation (Hartley & Hitch, 2022). The working memory tasks were carried out using the Smriti-Shravan software (Kumar & Maruthy, 2012).

The Operation Span task required participants to memorize a sequence of words (primary task) while judging the accuracy of mathematical equations (secondary task). Participants were presented with a mathematical equation on a computer screen and asked to determine its accuracy within 30 seconds by selecting “true” or “false.” Immediately after their response, a bisyllabic Kannada word appeared for two seconds for memorization. This process was repeated for three to seven elements per trial, in a random order of trial presentation. At the end of each trial, participants recalled the words in free order by selecting them on the screen within one minute. A practice trial was given to the participants for familiarization with the test. Performance was analyzed using Partial Credit Score Weighted (PCSW), calculated following the guidelines given by Conway et al. (2005). PCSW was obtained by summing the correctly recalled words across all trials (regardless of order) and dividing it by the total number of words presented. A minimum 85 percent accuracy in the secondary task was ensured for all participants (Sanchez et al., 2010).

The Backward Digit Span task required the participants to listen carefully to each digit sequence and, upon completion, recall the digits in reverse order by typing them into the system. Practice trials with three- and four-digit sequences were provided to ensure task familiarity. Stimuli consisted of randomized sequences of Kannada digits, presented binaurally at 70 dB SPL through headphones, with an interstimulus interval of 1 second. The task followed an adaptive one-up, one-down procedure (Kumar & Maruthy, 2012), starting with three-digit sequences. The sequence length increased by one digit after correct responses and decreased by one digit after incorrect responses. This procedure continued until six reversals were obtained. The Backward Digit Span was calculated as the mean of the last four reversal levels, where the reversal level was determined as the midpoint between the last correct and the first incorrect sequence.

Attention is defined as the selective allocation of cognitive resources to relevant stimuli while suppressing irrelevant information. In this study, auditory attention was measured through the speed and accuracy of detecting target stimuli, typically quantified using reaction time in response to auditory cues (Noyce et al., 2023). The test of attention in listening (Zhang et al., 2012) was administered in the control condition, where the participants were required to press a button as soon as the second tone was heard. Tone intensity was 70 dB SPL, and tone duration ranged from 100 to 300 ms. A silent gap of 300 ms between the two tones was presented. The test was run in four blocks of 10 trials each. A demo of five trials was given to familiarize the participants. The reaction time on the detection task was measured as a proxy for attention toward listening.

Listening effort is the amount of cognitive resources exerted to understand spoken language, especially in acoustically or linguistically challenging environments. We measured listening effort using a dual-task paradigm where greater difficulty on a secondary task indicates increased effort. Listening effort was assessed using the Listening Effort and Fatigue Software developed by Kumar and Hemanth (2018), following the dual-task paradigm proposed by Pichora-Fuller et al. (1995). The primary task required the participants to listen to Kannada sentences (Geetha et al., 2014) presented binaurally at 70 dB SPL in speech-shaped noise at 0 dB signal-to-noise ratio. They were required to repeat the last word of each sentence. The secondary task was to recall the repeated words after every five sentences in any order. Their Repeat and Recall responses were recorded, and they were encouraged to guess if uncertain. The maximum obtainable score was 50 for the Repeat task and 10 for the Recall task, as per the scoring criteria described. The scores were calculated as follows:

Repeat score=Σ Sum of scores in each block
Recall score=Σ Recall scores of all blocks/number of blocks.

The order of the cognitive tests was randomized across participants to control for order effects. Ample breaks were provided between the tests to minimize fatigue.

RESULTS

The data obtained for the tasks (PCSW, Backward Digit Span, Reaction Time for the auditory detection task, and Repeat and Recall scores) were statistically analyzed using the SPSS version 26 software. Shapiro-Wilks test for normality showed the data were normally distributed (p > 0.05), except for the PCSW for the vestibular migraine group (p = 0.041). Descriptive statistics were carried out, and the mean and standard deviation (SD) of the test scores for both groups are depicted in Table 3 and graphically in Figure 1.

Table 3.

The mean and standard deviation (SD) for the Test Scores in Both Groups

Normal vestibular function Vestibular migraine
Mean SD Mean SD
PCSW 0.883 0.109 0.722 0.197
BDSpan 3.992 0.822 3.594 1.556
RT 0.355 0.059 0.492 0.169
RepeatS 43.900 2.923 31.92 6.855
RecallS 5.680 0.900 3.733 1.007
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BDSpan = Backward Digit Span score; RepeatS = Repeat score of the listening effort task; RecallS = Recall score of the listening effort task; RT = Reaction Time in detection task.

Figure 1.

Figure 1.

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The mean and standard deviation of the various test scores. (A) PCSW for operation span task, (B) Backward Digit Span score, (C) Reaction Time in detection task, (D) Repeat scores, and (E) Recall score for the listening effort task. Asterisks indicate a significant difference between the groups (*p < 0.05). NVF = normal vestibular function; VM = vestibular migraine.

The means of the PCSW and Backward Digit Span were greater for the control group compared with the vestibular migraine group. The Reaction Times of the control group were faster than those of the vestibular migraine group. The Repeat and Recall scores of the control group were greater than those of the vestibular migraine group.

Inferential statistics were conducted to determine whether the differences in group means were statistically significant. Because the data were normally distributed, independent t test was carried out (Table 4).

Table 4.

The t Value, p Value, and Cohen’s d (for Effect Size) of Different Test Scores Between the Groups

t value p value Cohen’s d
PCSW 2.244 0.034* 1.011
BDSpan 0.702 0.490 –
RT −2.607 0.015* 1.082
RepeatS 5.445 0.000018* 2.273
RecallS 4.967 0.000057* 2.038
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*

p < 0.05.

BDSpan = Backward Digit Span score; RepeatS = Repeat score of the listening effort task; RecallS = Recall score of the listening effort task; RT = Reaction Time in detection task.

The PCSW was significantly greater for the individuals in the control group than those with vestibular migraine, indicating poorer memory performance under multitasking conditions in the latter group. This difference was associated with a large effect size, suggesting a substantial effect of vestibular migraine on the ability to manage dual demands of processing and storage (Sullivan & Feinn, 2012). However, the Backward Digit Span scores were not significantly different between the two groups, implying that the working memory as assessed by this task is relatively preserved in individuals with vestibular migraine, or that the measure may be less sensitive to subtle cognitive differences.

Auditory attention, which was assessed by measuring the Reaction Time for the auditory detection task, was significantly different between the groups. The control group had significantly faster Reaction Times than individuals with vestibular migraine, reflecting reduced sustained attention in the group with vestibular migraine. The large effect size indicates a meaningful impact of the disorder on the auditory attention capabilities.

The raw scores of the Repeat and Recall tasks, which are a measure of listening effort, showed significant differences between the groups. The Repeat and Recall Scores were significantly greater in the control group compared with the individuals with vestibular migraine, indicating reduced listening effort in the control group. This difference was associated with a very large effect size, suggesting that significantly greater mental effort was required to perceive and recall speech.

DISCUSSION

This study’s findings indicate that individuals without vestibular migraine performed better on cognitive tasks than those with vestibular migraine. This suggests that vestibular dysfunction, particularly in the context of vestibular migraine, negatively affects cognitive processes such as working memory, auditory attention, and listening effort.

The mean age of the vestibular migraine and control groups differed by almost a decade (35.14 vs. 25.54 years, respectively). Although this age difference is notable, prior research shows that both attention and working memory remain relatively stable within this age range. Reaction time and digit span performance typically decline only in older age groups, suggesting that the age gap in this study is unlikely to influence the results significantly (Heled & Levi, 2024; Tun & Lachman, 2008).

The control group performed significantly better on the Operation Span task than the affected group. However, the difference in performance on the auditory Backward Digit Span task was not statistically significant. These findings align with the existing literature. For instance, Ahmad et al. (2022) have reported no significant differences in digit span performance (both forward and backward) among individuals with bilateral vestibular loss, individuals with unilateral vestibular loss, and healthy control subjects. In contrast, patients with bilateral vestibulopathy have shown significantly poorer performance on auditory and visual working memory tasks (Danneels et al., 2023). Similarly, patients with unilateral vestibular loss exhibited significantly lower Backward Digit Span scores compared with healthy control subjects (Ayar et al., 2020). In addition, vestibular migraine patients showed significantly impaired memory function across various tests, including recognition memory, memory for content, and memory for sequence tests (Tawfik et al., 2021). The differences in findings could be because of the task that has been used in different tests. Tawfik et al. (2021) have used a visual task, whereas in this study, an auditory task was used to assess memory.

Individuals with vestibular migraine exhibited slower reaction times than those in the control group, which is statistically significant. This suggests impaired sensory processing and reduced sustained attention in the clinical population. The slow reaction times may also indicate the presence of cognitive fatigue in individuals with vestibular migraine (Faber et al., 2012; Feltmate et al., 2020). Furthermore, greater variability in reaction times (in SD) was seen in the vestibular migraine group compared with the control group. This difference in the variability of the reaction times may suggest attention lapses or difficulty sustaining focus in the group with vestibular migraine. Because the vestibular apparatus communicates with the limbic system, which regulates emotions, memory formation, decision-making, and other higher cognitive functions (Efimova & Volkova, 2023; Guidetti & Guidetti, 2014; Ribeiro et al., 2023; Smith, 1997), it might have affected the results.

Electrophysiological studies further support these findings. Ma et al. (2023) reported significantly prolonged P300 latencies and reduced amplitudes with increasing severity of vestibular symptoms. However, Kumar et al. (2022) observed no significant difference in the latency and amplitude of P300 between individuals with vestibular dysfunction and healthy control subjects. However, they observed that P300 was absent in more individuals with vestibular dysfunction. Because P300 serves as a measure of attention (Uehiro et al., 2022), it can be seen that attention is affected in the earlier studies. Also, behavioral tests for attention using the Stroop task showed no significant difference between the vestibular disorder and the control groups (Ahmad et al., 2022). The difference between their finding and current test findings could be because of the use of visual and auditory tasks.

The results of the listening effort tasks showed that both the Repeat and Recall scores were better in the control group than in the group with vestibular migraine. This suggests that individuals with vestibular migraine require a greater mental effort to understand speech than healthy controls. Similar findings have been reported in other studies with different vestibular pathological conditions. Individuals with Ménière’s disease have been reported to score poorly on word recognition tasks in quiet situations (Cohen et al., 2024; McMullen et al., 2017). Speech perception in noise was also reported to be significantly poorer in individuals with vestibular migraine than in healthy controls (Emami et al., 2012; Tawfik et al., 2021). This study also suggests that individuals with vestibular migraine require greater effort to perceive speech in the presence of noise and to recall the speech. The additional listening effort required by the vestibular migraine population could be because of the interconnection between the vestibular apparatus and other cortical centers that control emotion, cognition, etc. (Efimova & Volkova, 2023; Guidetti & Guidetti, 2014; Ribeiro et al., 2023; Smith, 1997).

The neurophysiological connection between the vestibular and other cortical structures could explain the possible reason for abnormal results in this study. Surgent et al. (2019) observed that balance functions are associated with several neural structures, including the brainstem and cerebellar region. Several other cortical structures are also associated with balance, including the superior frontal gyrus, primary motor cortex, inferior orbitofrontal cortex, and supplementary motor areas of the frontal lobe, as well as the hippocampus and subcortical regions, such as the basal ganglia and thalamus, along with the occipital and parietal lobes. These areas are either associated with auditory or both auditory and visuospatial attention (Paus, 2000). Memory-related structures such as the amygdala, hippocampus, cerebellum, and prefrontal cortex are also implicated in individuals with balance disorders (Yavas et al., 2019). Given the involvement of these brain areas, vestibular migraine is likely to alter cognitive abilities, particularly in domains such as attention and memory.

This study shows that individuals with vestibular migraine perform more poorly on cognitive tasks—particularly in working memory, attention, reaction time, and listening effort—compared with those with normal vestibular function. The challenges faced by these individuals may stem from impaired sensory processing and the vestibular system’s interaction with brain regions involved in cognition and emotion. Importantly, the findings validate patients’ experiences of mental fog, difficulty focusing, and hearing challenges that may not be evident in standard audiological tests. Clinically, this highlights the need to address not only vestibular or migraine symptoms but also the broader cognitive and functional impacts on daily life, communication, and work performance.

However, this study has some limitations. Diagnosis was based solely on clinical criteria, and no objective vestibular function tests were conducted to confirm or quantify vestibular impairment. This limits the ability to differentiate between central and peripheral vestibular contributions to the observed cognitive effects. In addition, the relatively small sample size limits the statistical power of the study and may reduce the ability to detect subtle effects. Future studies with larger and more diverse samples are needed to confirm and extend these findings.

CONCLUSIONS

This study evaluated performance in individuals with vestibular migraine and found that they scored significantly lower than their healthy counterparts on all measures, except for Backward Digit scores. These findings support earlier research indicating that the vestibular system interacts with the limbic system, which regulates emotions, memory, decision-making, and other higher cognitive functions. This suggests that the vestibular system has a broader influence beyond motor control, potentially impacting cognitive and auditory performance in individuals with vestibular migraine. As a result, the study highlights the importance of early identification of vestibular migraine and the need for a holistic assessment approach that includes cognitive screening alongside vestibular evaluation. Awareness of these challenges can aid in patient counseling (about its potential effects on cognition and auditory perception), facilitate targeted interventions (e.g., cognitive strategy training, auditory and vestibular rehabilitation), and improve overall management by addressing both sensory and cognitive symptoms.

Acknowledgments

The authors thank the Director of All India Institute of Speech and Hearing.

Abbreviations

dB SPL

decibels sound pressure level

ms

milliseconds

PCSW

Partial Credit Score Weighted

SD

standard deviation

Footnotes

Any mention of a product, service, or procedure in the Journal of the American Academy of Audiology does not constitute an endorsement of the product, service, or procedure by the American Academy of Audiology.

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