Utriculo-ocular pathway dysfunction is more frequent in vestibular migraine than probable vestibular migraine

Clinical characteristics of probable vestibular migraine

BackgroundThe International Classification of Vestibular Disorders defines probable vestibular migraine (PVM) as an episodic vestibular disorder with either a history of migraine (criterion B) or migraine features during vestibular episodes (criterion C).ObjectiveThe purpose of this study is to investigate the clinical characteristics of PVM, focusing on items in the diagnostic criteria.MethodsWe retrospectively reviewed the medical records of 30 consecutive PVM patients diagnosed according to the Barany classification. The PVM patients were divided into two groups: those who fulfilled the criterion B (pre-existing migraine group) and those who fulfilled the criterion C (migraine features group).ResultsTwenty-four patients (80%) were in the pre-existing migraine group and the remaining 6 patients (20%) were in the migraine features group. All patients in the migraine features group had headache episodes. There were no significant differences between the two groups with regard to prevalence of migraine features listed in the criterion C and abnormal testing results.ConclusionsThe diagnosis of PVM was based on a history of migraine in most patients and on migraine features during vestibular episodes only in a few. All patients with migraine features during vestibular episodes had also headache episodes.

Correlating Migrainous Features With Vestibular-Evoked Myogenic Potentials in Vestibular Migraine

OBJECTIVE

This study aimed to find biomarkers for assessing migrainous features, that is, migrainous headache, sensitivity to sound and light (phono- and photophobia) and visual aura in vestibular migraine (VM) patients.

DESIGN

A retrospective cohort study.

SETTING

University hospital.

PARTICIPANTS

A total of 400 definitive VM patients were classified into four groups based on the number of migrainous features. Group A (n = 45) had one migrainous feature (migrainous headache). Group B (n = 70) had migrainous headache along with phono- and photophobia, while Group C (n = 55) had migrainous headache and visual aura. Those with all three migrainous features were categorised in Group D (n = 230). Another 40 healthy subjects were also enrolled for comparison.

MAIN OUTCOMES MEASURE

All subjects underwent an inner ear test battery comprising audiometry, cervical, ocular vestibular-evoked myogenic potential (cVEMP, oVEMP) and caloric tests.

RESULTS

Significant difference in mean age was observed in Group A when compared to Groups B-D, indicating that younger age might not be associated with the manifestation of all three migrainous features. No significant difference was observed among the four groups irrespective of gender and inner ear test battery. Via multivariate logistic regression, the oVEMP test (adjusted odds ratio, aOR = 2.60) was superior to the cVEMP test as a stronger indicator for the presence of phono- and photophobia. Conversely, the cVEMP test (aOR = 2.59) served as a stronger indicator for the presence of visual aura than the oVEMP test.

CONCLUSION

The oVEMP test may act as a biomarker for phono- and photophobia, whereas the cVEMP test shows a strong capacity to predict visual aura.

Postural stability in patients with vestibular migraine and probable vestibular migraine in the absence of acute vestibular symptoms

PURPOSE

To investigate postural stability in patients with vestibular migraine (VM) and probable vestibular migraine (PVM) in the absence of acute vestibular symptoms.

METHODS

We retrospectively reviewed the medical records at our balance disorder clinic. The 30 consecutive VM patients and 25 consecutive PVM patients enrolled in this study all underwent foam posturography. 194 healthy control subjects with no history of dizziness or balance dysfunction was also enrolled. Multiple regression analyses were performed to see whether subjects' age, sex, or diagnosis (VM, PVM and control) were associated with the posturographic findings. Dependent variables were the mean velocity of the center of pressure movement (velocity) and the area enclosed by the center of pressure movement (area) in Fixed/Open, Fixed/Closed, Foam/Open and Foam/Closed conditions, the Romberg's ratio in Velocity/Fixed, Velocity/Foam, Area/Fixed and Area/Foam conditions, and the foam ratio in Velocity/Open, Velocity/Closed, Area/Open and Area/Closed. Independent variables were sex (male, female), age, and diagnosis (VM, PVM and control).

RESULTS

VM and PVM patients showed significantly increased velocity and area compared to healthy controls with and without foam rubber. VM and PVM patients showed significantly lower foam ratios compared to healthy controls in velocity and area, both with open and closed eyes. On the other hand, there were no significant differences in velocity or area, Romberg's ratio or foam ratio between VM patients and PVM patients in any conditions.

CONCLUSIONS

Both VM and PVM patients had more postural instability than healthy controls. There were no differences in postural stability between VM and PVM patients.

Prognostic significance vestibular examination results in patients with vestibular migraine

Introduction

Vestibular migraine (VM) is a newly defined clinical condition. Several vestibular abnormalities have been reported in patients with VM. However, to date, no specific vestibular examinations are used to define VM. Therefore, the utility of vestibular examinations is limited. Currently, the role of vestibular examination has not been clearly defined. We speculated that the results of vestibular examinations could predict the prognosis of VM. We investigated the relationship between the vestibular examination results and clinical outcomes in patients with VM.

Methods

This study included 25 patients with VM. Vestibular examinations, including the video head impulse test (V-HIT), cervical and ocular vestibular evoked myogenic potential (c-VEMP and o-VEMP), posturography, and several questionnaires, including the Dizziness Handicap Inventory (DHI), were conducted at the initial evaluation. Lifestyle modifications for VM and conventional pharmacological prophylactic treatments, including lomerizine, amitriptyline, and valproic acid, were performed. After 4 weeks of treatment, clinical improvements were evaluated using the Clinical Global Improvement Scale (CGI-s). The relationships among the CGI-S score, several clinical variables, and the results of several vestibular examinations were evaluated. Each patient was further classified into two subgroups according to treatment outcomes concerning vertigo and headache: CGI-S score from 0 to 2 (good response [GR]) and CGI-S score > 3 (poor response [PR]).

Results

Overall, after treatment, most of the patients had improved dizziness and headache, and the CGI-s was 2.7 ± 1.3. There were 12 GRs, and 13 had PRs. Thus, neither V-HIT nor posturography predicted the prognosis. For c-VEMP, patients with GRs had significantly small AR concerning PR (19.2 ± 12.8 and 62.5 ± 42.5, respectively, [p < 0.01]). There were five normal, six unilateral, and 14 bilateral no response in 500hz o-VEMP. CGI-s of normal, unilateral, and bilateral no response was 1.4 ± 0.5, 2.8 ± 1.3, and 3.1 ± 1.2, respectively. There was a statistically significant difference between the normal and bilateral non-response o-VEMP groups (p < 0.05).

Conclusion

Patients with VM had improvements in both headache and vertigo through a combination of lifestyle changes and prophylactic medications. Vestibular examinations, especially o- or c-VEMP, are beneficial for predicting the treatment outcomes of VM. The pathophysiology of VM is closely related to vestibular abnormalities, particularly the otolith-related pathways.

Interventional Study of Flunarizine Therapy on Symptom Relief and Vestibular Evoked Myogenic Potential Changes in Individuals with Vestibular Migraine

INTRODUCTION

Migraine is the third most common disease in the world with an estimated prevalence of 14.7%. The purpose of this study was to identify the characteristic changes in cervical and ocular vestibular evoked myogenic potential (VEMP) and analyse changes in symptoms and VEMP after flunarizine therapy in patients diagnosed with vestibular migraine (VM).

METHODS

Prospective interventional study was conducted on 31 VM patients. Cervical VEMP (cVEMP) and ocular VEMP (oVEMP) were recorded. Flunarizine (10 mg) was given once daily for two consecutive months. Prophylactic therapy was monitored with a monthly follow-up assessment of their symptoms and VEMP was repeated after 2 months.

RESULTS

Headache was the chief complaint (67.7%). Vertigo was spontaneous and mostly moderate in intensity (93%). cVEMP was absent in 1 patient and oVEMP was absent in 3 patients. Post prophylactic treatment with flunarizine, there was significant reduction in the frequency (p = 0.001) and duration (p = 0.001) of headache and frequency (p = 0.001), duration (p = 0.001), and intensity (p = 0.009) of vertigo. cVEMP and oVEMP showed no significant differences (p > 0.05) between pre- and post-treatment recordings.

CONCLUSION

Treatment with flunarizine helps in considerably reducing the episodes and duration of headache, as well as episodes, duration, and intensity of vertigo.

Video Head Impulse Test Demonstrates a Residual Function after Plugging of Dehiscent Superior Semicircular Canal

OBJECTIVE

Plugging a symptomatic dehiscent superior semicircular canal (SSCC) often leads to a nonfunctional postoperative canal. However, in some instances, a residual function has been described. This study attempts to describe what factors may lead to such residual function.

STUDY DESIGN

Retrospective study.

SETTING

Tertiary referral center.

PATIENTS

Thirty-five patients with confirmed SSCC dehiscence.

INTERVENTION

Video head impulse test was conducted pre- and postoperatively to assess any difference in the function of the SSCC.

MAIN OUTCOME MEASURES

Mean gain and pathological saccades were recorded according to well-established thresholds along with dehiscence length and location to evaluate any associations to residual canal function.

RESULTS

When comparing preoperative to postoperative SSCC abnormal gains, a significant increase was observed after plugging ( p = 0.023). This also held true when abnormal gain and pathologic saccades were taken together ( p < 0.001). Interestingly, 55.3% of patients were observed to remain with a residual SSCC function 4 months postoperatively even with a clinical improvement. Of these, 47.6% had normal gain with pathologic saccades, 38.1% had an abnormal gain without pathologic saccades, and 14.3% had normal gain without pathologic saccades (normal function). Preoperatively, SSCC abnormal gain was associated with a larger dehiscence length mean ( p = 0.002). Anterosuperior located dehiscences were also associated with a larger dehiscence length mean ( p = 0.037). A residual SSCC function after plugging was associated with a shorter dehiscence length regardless of location ( p = 0.058).

CONCLUSION

Dehiscence length and location may be useful in predicting disease symptomatology preoperatively and canals function recovery after plugging. These factors could be used as indicators for preoperative counseling and long-term management.

Electrodermal and postural responses in dizzy adults: Diagnostic indicators of vestibular migraine

INTRODUCTION

No reliable biometric measurement of vestibular involvement with migraine is currently available.

OBJECTIVE

Measures of autonomic nervous system and postural responses could serve as quantifiable indicators of vestibular involvement with migraine.

METHODS

A convenience sample of 22 young healthy adults (34±9 years old) and 23 young adults (34±8 years old) diagnosed with vestibular migraine (VM) participated. A rod and frame test and clinical outcome measures of dizziness and mobility were administered. Participants stood on foam while viewing two dynamic virtual environments. Trunk acceleration in three planes and electrodermal activity (EDA) were assessed with wearable sensors. Linear mixed models were used to examine magnitude and smoothness of trunk acceleration and tonic and phasic EDA. A Welch's t-test and associations between measures were assessed with a Pearson Correlation Coefficient. Effect sizes of group mean differences were calculated using Cohen's d.

RESULTS

Visual dependence was present in 83% of the VM population. Individuals with VM exhibited lower baseline EDA (t(4.17) = -7.2, p = 0.001) and greater normalized trunk accelerations in the vertical (t(42.5) = 2.861, p = 0.006) and medial (t(46.6) = 2.65, p = 0.01) planes than healthy participants. Tonic EDA activity increased significantly across the period of the trial (F (1,417) = 23.31, p = 0.001) in the VM group. Significant associations appeared between vertical trunk acceleration and EDA, Dizziness Handicap Inventory, and Activities of Balance Confidence tools.

CONCLUSIONS

Higher tonic EDA activity in healthy adults results in more accurate postural reactions. Results support the supposition that EDA activity and postural acceleration are significantly different between VM and healthy individuals when accommodating for postural instability and visual-vestibular conflict.

Study of clinical correlation of motion sickness in patients with vestibular migraine

Objective

In this study, clinical data from vestibular migraine (VM) patients and healthy control populations were collected to analyze the clinical data of VM patients, especially the history of motion sickness, and to understand their clinical characteristics.

Methods

According to VM diagnostic criteria, 140 patients diagnosed with confirmed VM (cVM) and probable VM (pVM) who attended the outpatient and inpatient ward of Jiaxing First Hospital between August 2017 and June 2021, as well as 287 healthy check-ups in the health management center, were analyzed and compared in terms of age, gender, and previous history of motion sickness.

Results

A comparison of clinical data related to VM patients and the control population showed that there were more women in the VM group (P < 0.01) and that patients in the VM group were older (P < 0.05) and had a higher prevalence of history of motion sickness history (P < 0.01). Analysis after matching gender and age revealed that patients in the cVM group were older than those in the pVM group (P < 0.05), but the proportion of motion sickness was lower than in the pVM group (P < 0.05). The age of the patients in the cVM group was mainly distributed around 50 years of age, following a normal distribution, whereas the age distribution of the patients in the pVM group did not have a significant trend of age concentration and was distributed at all ages.

Conclusion

The history of motion sickness is significant in patients with VM and may be a potential suggestive factor for the diagnosis of VM.

Isolated Otolith Dysfunction in Persistent Postural-Perceptual Dizziness

The aims of this study were to investigate otolith dysfunction, especially isolated otolith dysfunction (with preserved semicircular canal function) in persistent postural-perceptual dizziness (PPPD) patients. Twenty-one patients who had been diagnosed with PPPD were enrolled in this study. The subjects filled out questionnaires [the Dizziness Handicap Inventory (DHI) and the Niigata PPPD Questionnaire (NPQ)] and underwent vestibular evoked myogenic potential (VEMP) tests, video head-impulse tests (vHIT), and stabilometry. Among the 21 subjects with PPPD, 9 showed isolated otolith dysfunction, 4 exhibited both otolith dysfunction and semicircular canal dysfunction, and 2 demonstrated isolated semicircular canal dysfunction. Six subjects exhibited normal VEMP and vHIT results. Concerning the subjects' questionnaire scores and stabilometric parameters, there were no significant differences among subgroups when the subjects were classified according to their VEMP and vHIT results while stabilometric parameters obtained in PPPD subjects were significantly increased than published data of healthy subjects. As precipitating conditions for PPPD, vestibular neuritis was the most frequent and the second most was idiopathic otolithic vertigo. In conclusion, the majority of PPPD patients had otolith dysfunction, and most of them showed isolated otolith dysfunction. Idiopathic otolithic vertigo can be a precipitating factor of PPPD. While otolith dysfunction may be associated with initiation of PPPD symptoms, PPPD symptoms are also considered to be associated with other dysfunctions of the sensory processing system.

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.