Factors implicated in response to treatment/prognosis of vestibular migraine

Vestibular migraine: course of symptoms during a four-year follow-up

Background and objective

Data about the prognosis of vestibular migraine (VM) is scarce. VM patients on follow-up for at least 4 years were included in this multicenter study to evaluate the course of symptoms.

Methods

This is a cross-sectional study. A structured questionnaire was used inquiring demographic features, age of onset of migraine headaches and vertigo attacks, headache and vertigo attack frequency, severity, associated features and the presence of interictal dizziness and positional vertigo. Menopause, history of motion sickness, and family history of migraine were recorded. Answers of the first visit were compared with the answers of the last visit. In addition, variables considered were evaluated regarding their effect on the symptom course.

Results

203 patients were studied. Median vertigo and headache attack frequency and severity had significantly dropped during follow-up (p < 0.01 for all comparisons). Complete resolution was reported by only 5.4%. Dizziness between the attacks was present in 67%, and positional vertigo was reported by 20.2%. Univariate analysis showed that aural symptoms (p = 0.013) and menopause (p = 0.016) were risk factors for ongoing frequent vertigo attacks. A history of motion sickness (p = 0.019) and a family history of migraine (p = 0.004) were associated with the risk of frequent migraine headaches. The presence of allodynia (p = 0.002) was associated with severe headache attacks while an early age of onset of vertigo attacks (p = 0.005) was a risk factor for continuing high-frequency vertigo attacks.

Conclusion

Though the frequency and severity of headache and vertigo attacks decrease, complete resolution is reported by a minority.

Efficacy of Nortriptyline and Migraine Lifestyle Modifications in Vestibular Migraine Management

OBJECTIVE

To evaluate the effectiveness of nortriptyline regimen and migraine dietary/lifestyle modifications on dizziness and stress levels in patients diagnosed with vestibular migraine (VM).

METHODS

A total of 35 patients diagnosed with definite VM based on the International Classification of Headache Disorders were included in this intervention study. Patients self-selected to receive either nortriptyline regimen alone (10-40 mg daily with biweekly escalation) (group A, n = 17) or migraine dietary/lifestyle modifications alone (group B, n = 18). Main outcome measures were dizziness severity and stress level measured by the visual analog scale (VAS).

RESULTS

At 4-week post-treatment, dizziness decreased from 6.0 ± 2.5 to 4.2 ± 3.4 (p = 0.069) in group A and from 8.7 ± 1.5 to 3.6 ± 3.0 (p < 0.001) in group B. VAS for stress changed from 5.5 ± 1.3 to 5.4 ± 2.9 (p = 0.93) and from 6.9 ± 3.2 to 5.0 ± 2.7 (p = 0.025) in groups A and B, respectively. The δ values of the VAS score for dizziness were 1.8 ± 3.7 and 5.1 ± 3.1 and the δ values of the VAS score for stress were 0.06 ± 2.9 and 1.9 ± 3.3 in groups A and B, respectively. Quality of life (QOL) improved in 88% patients in group A and 94% patients in group B.

CONCLUSIONS

Nortriptyline, at a maximum dose of 40 mg, effectively alleviates patient symptoms, while a migraine diet and lifestyle modifications notably reduce vertiginous symptoms and stress levels in VM patients in 4 weeks. Both interventions are equally effective in ameliorating the QOL of patients. The ideal treatment for patients would likely need to include both medication and diet/lifestyle changes.

Hyperacusis and Tinnitus in Vestibular Migraine Patients

OBJECTIVES

To estimate the prevalence of tinnitus and hyperacusis in patients with vestibular migraine (VM), and to define the association with hearing loss, anxiety, and depression.

DESIGN

A cross-sectional, multicenter study including 51 adult patients with definite or probable VM, defined according to the Barany Society diagnostic criteria. Audiological examinations were performed by pure tones extended to high frequencies to assess hearing thresholds. Psychoacoustic (pitch, masking level, and residual inhibition) and psychometric assessment of tinnitus was performed in all patients that reported tinnitus with the following questionnaires: Tinnitus Handicap Inventory (THI), Hypersensitivity to Sound Questionnaire and Hospital Anxiety Depression Scale. Correlation and regression analyses were used to assess the relationship between THI scores hyperacusis, anxiety, and depression in patients with VM.

RESULTS

Forty-five of 50 VM patients (90%) were females; 38 out of 50 (75%) patients reported tinnitus. In our series, the most common frequency (pitch) for tinnitus was 8000 Hz. Tinnitus was not associated with hearing loss in patients with VM and the hearing thresholds were similar in VM patients with or without tinnitus. Hyperacusis was reported in 35 (60%) individuals, and in patients with tinnitus, the THI scores were associated with higher scores in Hypersensitivity to Sound Questionnaire, and anxiety and depression subscales of Hospital Anxiety Depression Scale. There were differences in the distribution of hearing loss in patients with hyperacusis, however both groups did not exceed the normal hearing threshold (17.18 ± 13.43 patients with hyperacusis and 11.66 ± 5.41, p = 0.023 in patients without hyperacusis).

CONCLUSIONS

Tinnitus is a common symptom in patients with VM and it is not related to hearing loss in the standard audiogram. Hyperacusis was associated with tinnitus, anxiety, and depression, but it was not associated with hearing thresholds.

Vestibular Migraine Pathophysiology and Treatment: a Narrative Review

PURPOSE OF REVIEW

To review the diagnosis of vestibular migraine (VM) and update the clinician on the most recent developments in our understanding of its pathophysiology and treatment.

RECENT FINDINGS

Functional imaging studies have identified multiple regions of the brain with abnormal activity and connectivity in VM. There is evidence of abnormal sensory processing and integration in VM patients. Calcitonin gene-related peptide (CGRP) has also been found to play a role in trigeminal and vestibular nucleus pathways. Research into treatment modalities has identified several neuromodulation devices that may be effective in VM. There are a growing number of evidence-based preventive options for VM, including medications that target CGRP. VM is best understood as a sensory processing disorder. CGRP appears to play a role, and further research is needed to fully understand its effects. Treatment options are expanding, but there is still a need for more randomly controlled trials in this area.

Case Series: Vestibular Migraines in Fragile X Premutation Carriers

BACKGROUND

Vestibular migraine (VM) is one of the most common causes of recurrent vertigo and presents with a history of spontaneous or positional vertigo with a history of migraine headaches. While research has identified a high prevalence of migraine headaches and vestibular deficits among fragile X premutation carriers, there has been no discussion about VM within this population.

OBJECTIVE

This case series and review seeks to describe the clinical characteristics and pathophysiology of VM among individuals with the fragile X premutation. We also seek to discuss treatment and future steps in addressing VM in this population.

METHODS

A review of the literature regarding vestibular migraine and presentation of migraine headaches and vestibular deficits among premutation carriers was performed. A detailed clinical history of migraine headaches and vertigo was obtained from three patients with the fragile X premutation seen by the senior author (RJH).

RESULTS

All three cases first developed symptoms of migraine headaches earlier in life, with the development of VM near menopause. Two of the three cases developed progressive balance issues following the development of VM. All three cases found that their VM episodes were improved or resolved with pharmacological and/or lifestyle interventions.

CONCLUSIONS

It is important to recognize VM among premutation carriers because beneficial treatments are available. Future studies are needed regarding the prevalence of VM and the relationship to subsequent FXTAS. The pathophysiology of VM remains uncertain but possibilities include mitochondrial abnormalities, cranial nerve VIII toxicity secondary to neurotoxic protein accumulation, and calcitonin gene-related peptide (CGRP) signaling dysfunction due to altered levels of fragile X messenger ribonucleoprotein (FMRP).

Sense of direction in vestibular disorders

BACKGROUND

Our sense of direction (SOD) ability relies on the sensory integration of both visual information and self-motion cues from the proprioceptive and vestibular systems. Here, we assess how dysfunction of the vestibular system impacts perceived SOD in varying vestibular disorders, and secondly, we explore the effects of dizziness, migraine and psychological symptoms on SOD ability in patient and control groups.

METHODS

87 patients with vestibular disorder and 69 control subjects were assessed with validated symptom and SOD questionnaires (Santa Barbara Sense of Direction scale and the Object Perspective test).

RESULTS

While patients with vestibular disorders performed significantly worse than controls at the group level, only central and functional disorders (vestibular migraine and persistent postural perceptual dizziness), not peripheral disorders (benign-paroxysmal positional vertigo, bilateral vestibular failure and Meniere's disease) showed significant differences compared to controls on the level of individual vestibular groups. Additionally, orientational abilities associated strongly with spatial anxiety and showed clear separation from general dizziness and psychological factors in both patient and control groups.

CONCLUSIONS

SOD appears to be less affected by peripheral vestibular dysfunction than by functional and/or central diagnoses, indicating that higher level disruptions to central vestibular processing networks may impact SOD more than reductions in sensory peripheral inputs. Additionally, spatial anxiety is highly associated with orientational abilities in both patients and control subjects.

Long-Term Effects of Intervention on Vestibular Migraine: A Preliminary Study

BACKGROUND

Vestibular migraine is a common cause of vertigo. Intervention often includes preventive and/or rescue medications. Lifestyle modifications are often used along with medications but can be used as the sole intervention. There is lack of clarity regarding the long-term benefits of these interventions.

AIMS

The purpose of this study was to determine long-term effects of intervention types on dizziness in patients with vestibular migraine.

METHODS

Twenty-three participants were grouped based on intervention into preventive medication plus lifestyle modifications, rescue medication plus lifestyle modifications, or lifestyle modifications only. Outcomes were determined at ~372 days post intervention by comparing pre- and post-Dizziness Handicap Inventory scores. A difference of ≥18 points was considered a change and we also evaluated change in severity scale on this measure.

RESULTS

Using the group mean change score, only the rescue medication plus lifestyle modification group was significantly improved at 372 days of intervention. Considering all individual participants, 30% of the participants had improvement in dizziness at this point, regardless of intervention. Fifty percent of the rescue medication plus lifestyle modification group had significant reduction in dizziness, while the preventive medication plus lifestyle modification and the lifestyle modification only groups performed similarly using this criterion. Considering change in severity category, 43% of all participants improved by at least one category. The rescue medication plus lifestyle modifications and the lifestyle modifications only groups performed similarly with 50% of their respectively groups exhibiting improvement by at least one category. Notably, there was no worsening of dizziness for any participant in the lifestyle modification only group.

CONCLUSION

Our findings suggest that improvement in dizziness is maintained at ~372days of intervention in patients with vestibular migraine. Intervention using rescue medications plus lifestyle modifications had the best outcomes, followed by lifestyle modifications only. There was no worsening in dizziness for the lifestyle modification only intervention. More work is needed to better understand intervention effects, but it is encouraging that effects are maintained at greater than one year.

Vestibular migraine treatment: a comprehensive practical review

Vestibular migraine is an underdiagnosed but increasingly recognised neurological condition that causes episodic vertigo associated with other features of migraine. It is now thought to be the most common cause of spontaneous (non-positional) episodic vertigo, affecting up to 1% of the population. A meta-analysis of preventative treatments for vestibular migraine was published in 2021 but the authors were unable to establish a preferred treatment strategy due to low quality of evidence and heterogeneity of study design and outcome reporting. There remains therefore a clinical need for pragmatic management guidelines specific to vestibular migraine using the available evidence. Here we provide a practical review utilising a systematic qualitative assessment of the evidence for abortive and preventative interventions in adults. The overall evidence base for vestibular migraine treatment is of low quality. Nevertheless, we provide practical treatment recommendations based on the available evidence and our experience to help guide clinicians treating patients with vestibular migraine. We also discuss how future clinical trials could be designed to improve the quality of evidence in this condition.

Factors determining the response to treatment in patients with vestibular migraine

PURPOSE

To find out clinical features associated with poor response to treatment in vestibular migraine (VM).

METHODS

VM patients treated with drugs recommended in migraine prophylaxis were included in this multicenter study. Migraine features including type, age of onset of headache and vertigo attacks, attack frequency, intensity, associated symptoms, triggering factors, presence of interictal dizziness/imbalance, anxiety, depression, history of motion sickness, and family history of migraine were noted. Amitriptyline, flunarizine, propranolol, topiramate and venlafaxine were chosen depending on patients' individual requirements. Maximum dose of each drug was tried for 2 months to decide its efficacy. In the case of inefficacy, it was changed with another preventive drug of different class. If there was still no improvement, two drugs of different classes were combined. ≥ 50% reduction in attack frequency and severity in patients using one drug and a combination of two drugs was compared, with patients showing <50% reduction despite combination therapy, regarding their clinical features.

RESULTS

The results of 430 VM patients, 65 men and 365 women with a mean age of 42.2 ± 12.2 years (range: 17-74 years), were analyzed.

CONCLUSION

Cutaneous allodynia frequently associated with female sex, comorbid anxiety and depression and interictal dizziness/imbalance enhanced with comorbid anxiety were risk factors for reduced treatment response. Aural fullness might be the clue of impending concomitant Meniere's disease not responding to migraine preventives.

The Enduring Controversy of Cervicogenic Vertigo, and Its Place among Positional Vertigo Syndromes

The idea of cervicogenic vertigo (CV) was proposed nearly a century ago, yet despite considerable scrutiny and research, little progress has been made in clarifying the underlying mechanism of the disease, developing a confirmatory diagnostic test, or devising an appropriately targeted treatment. Given the history of this idea, we offer a review geared towards understanding why so many attempts at clarifying it have failed, with specific comments regarding how CV fits into the broader landscape of positional vertigo syndromes, what a successful diagnostic test might require, and some practical advice on how to approach this in the absence of a diagnostic test.

Do we need to reconsider the classification of vestibular migraine?

Introduction: Vestibular migraine (VM) is a complex disease characterized by recurrent episodes of migraine associated with vertigo attacks that are observed in 1-3% of the general population. Given its high prevalence and the impact on the health system, it is important to characterize these patients, in order to offer an accurate diagnosis and a proper treatment. As the diagnosis of VM is based on clinical features, the study of potential biomarkers has gained more interest in the last years, to improve the precision in the diagnosis of this disease. The aim of this review is to summarize the main tests available for the diagnosis of VM, including the accuracy of biomarkers for the diagnosis of VM.Areas covered: This review summarizes the main information on VM, including all diagnosis records published in the field in the last 10 years, and focusing on candidate biomarkers for the diagnosis of VM patients.Expert opinion: There is a limited knowledge in the pathophysiology of VM. The search of biomarkers for diagnosis of VM is needed to improve the precision in the diagnosis promoting clinical and translational research. The potential reclassification of VM will depend upon the discovery and validation of these biomarkers.