The cerebellum in migraine: a narrative review of anatomical, imaging, and clinical evidence

Migraine is usually framed through trigeminovascular pathways and interactions among the brainstem, hypothalamus, and cortex. The cerebellum has received less attention, although human studies place it within circuits that process trigeminal nociception and vestibular signals. This narrative review examines anatomical and experimental work together with imaging, genetic, and clinical studies, giving greatest weight to direct human migraine evidence. Repeated-measures imaging suggests that cerebellar connectivity changes across the migraine cycle, but the cohorts are small. Structural findings vary with analytic method, and population based testing does not show a general cerebellar deficit in common migraine. Evidence is more coherent in defined contexts: trigeminal stimulation recruits lobules VI/VIIIa and Crus I, vestibular migraine involves posterior cerebellar and wider vestibular-sensory networks, and treatment imaging shows cerebellar changes without localizing the site of CGRP-directed action. Findings in medication-overuse headache and familial hemiplegic migraine provide additional state-related and mechanistic clues. Taken together, the cerebellum is best viewed as a modulatory component of distributed migraine networks, with possible roles in sensory gain and vestibular integration. It is neither a demonstrated attack generator nor a validated treatment target. The next step is to test whether within-person cerebellar measures reproduce across attacks and whether intervention changes a prespecified circuit-level endpoint.