The integration of multisensory motion stimuli is impaired in vestibular migraine patients

vHIT and fHIT in Patients With Migraine, Vestibular Migraine, and Persistent Postural-Perceptual Dizziness

OBJECTIVE

Impairment in the integration of different vestibular stimuli is the proposed mechanisms in vestibular migraine (VM). In this study, it was aimed to assess the vestibulo-ocular reflex (VOR) and dynamic visual acuity (DVA) in patients with VM and to compare the results with migraine without vestibular symptoms (MwoV), and persistent postural-perceptual dizziness (PPPD) to find out if there are discriminative differences and search for a correlation with the levels of anxiety.

METHODS

Twenty-two patients with MwoV, 23 patients with VM, 22 patients with PPPD, and 23 healthy controls (HC) were studied. Video head impulse test (vHIT) and functional head impulse test (fHIT) without and with an optokinetic background (OB) were performed. Percentage of correctly identified optotypes (CA%) was considered for the fHIT test. Beck anxiety inventory (BAI) was used to assess anxiety.

RESULTS

Lateral canal vHIT gain of the patient groups were not different from the healthy controls (p > 0.05). fHIT and fHIT/OB CA% results of all patient groups were lower than the HC (p < 0.005), and VM patients had the lowest scores for both tests. BAI scores of the PPPD patients were the highest and a correlation between anxiety levels, and fHIT results could not be identified (p > 0.05).

CONCLUSION

Prominent CA% drop by the use of an OB was the main finding in patients with VM. This discriminative feature was not correlated with anxiety scores. Difficulty in resolving the conflict between visual and vestibular inputs seem to be the underlying mechanism.

LEVEL OF EVIDENCE

3 Laryngoscope, 2024.

Motion sickness whilst reading as a passenger in the car is highly predictive of vestibular migraine

Background

Vestibular Migraine (VM) is a prevalent vestibular disorder, affecting up to 2.7% of the general population. Despite the establishment of diagnostic criteria by the Bárány Society and its inclusion in the International Classification of Headache Disorders, the clinical diagnosis of VM remains challenging due to its complex pathophysiology and symptom overlap with other dizziness disorders. Motion sickness is a core feature of migraine and can be interrogated through simple questionnaires.

Objective

This study aims to identify to what extent motion sensitivity can predict VM compared to other causes of dizziness.

Methods

We conducted a cross-sectional study involving 113 patients from the vestibular neurology clinics at University College London Hospitals. Participants were categorized into VM, Persistent Postural Perceptual Dizziness (PPPD), combined VM and PPPD, and 'other' dizziness etiologies. Data on motion sickness history and dizziness during car travel were collected through structured interviews and analyzed using logistic regression to assess the predictive value of these symptoms for VM.

Results

A substantial portion of patients with VM (91.2%) reported nausea or dizziness when reading as a passenger, a symptom significantly more prevalent than in those with PPPD or other dizziness diagnoses. Logistic regression indicated that VM patients are significantly more likely to experience these symptoms compared to non-VM patients, with an odds ratio suggesting a strong predictive value for this symptom in diagnosing VM.

Conclusion

The findings highlight increased motion sensitivity while reading in a moving vehicle as a promising diagnostic tool for VM, offering a practical aid in clinical settings to distinguish VM from other vestibular disorders.

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.

Role of the functional head impulse test in evaluating vestibulo-ocular reflex abnormalities in individuals with Parkinson's disease

PURPOSE

To assess vestibular-ocular reflex (VOR) function in patients with Parkinson's disease (PD) using a new method called functional head impulse test (fHIT).

STUDY DESIGN

Case-control study.

SETTING

Tertiary medical center.

PARTICIPANTS

Twenty individuals with PD were recruited for PD group, and twenty healthy individuals for the control group. Ages of both groups ranged from 47 to 76 years.

MAIN OUTCOME MEASURES

According to the modified Hoehn-Yahr score, PD group was classified as an early stage with a range of 1-2.5 and a mid-late stage with a range of 3-5. Percentage of correct answers (%CA) was calculated using fHIT for lateral, anterior and posterior semicircular canal (SCC) planes.

RESULTS

PD group had statistically lower fHIT %CA in the right lateral, left lateral, and left posterior SCC planes compared to control group (p < .05). There was no statistical difference between two PD severity groups and functional VOR abnormality.

CONCLUSION

It was concluded that the functional VOR in the right lateral and left lateral and left posterior SCC plane was affected in individuals with PD. Our results show that impaired VOR and reduced dynamic visual acuity should be considered in individuals with PD for vestibular rehabilitation exercises.

Vestibular test results in patients with vestibular migraine and Meniere's Disease

BACKGROUND

Vestibular migraine (VM) and Meniere's Disease (MD) are episodic vestibular disorders, sometimes difficult to differentiate from each other on clinical grounds.

OBJECTIVE

To evaluate vestibular test results of the two groups that may help in the differential diagnosis.

METHODS

Twenty-two patients with VM, 21 patients with definite MD and 21 healthy volunteers (HC) were studied. Pure tone hearing thresholds (PTHT), cervical vestibular evoked myogenic potentials (cVEMPs), video head impulse test (vHIT) and functional head impulse test (fHIT) were performed.

RESULTS

PTHT of the MD-affected ears were significantly higher than VM and HC groups (p < .001 for both) when cVEMP amplitudes were lower (p = .005 for HC), (p = .006 for VM). Lateral canal vHIT gain of the MD-affected ears were lower than VM patients (p = .003) and the HC (p < .001). The percentage of correctly identified optotypes (CA%) on fHIT was low for both patient groups when compared with the HC (p < .001).

CONCLUSION

In addition to hearing loss, low cVEMP amplitudes on the affected side with decreased gain on vHIT indicate disturbed saccular and lateral semicircular canal functions in MD patients differentiating them from VM. A functional deficit in gaze stabilization detected by fHIT is the only abnormality found in patients with VM.

Altered large-scale internetwork functional connectivity in patients with vestibular migraine and migraine without aura

OBJECTIVE

To investigate large-scale internetwork functional connectivity in patients with vestibular migraine (VM) and migraine without aura (MwoA).

METHODS

Resting-state functional magnetic resonance imaging data from 34 VM patients, 34 MwoA patients, and 33 healthy controls (HCs) were collected and the results were analyzed using independent component analysis (ICA). We also analyzed the correlations between clinical data and internetwork functional connectivity.

RESULTS

In contrast to HCs, MwoA patients showed decreased functional connectivity between the left frontoparietal network (lFPN) and right frontoparietal network (rFPN), with increased functional connectivity between the sensorimotor network (SMN) and lateral visual network (lVN). When compared to MwoA patients, VM patients demonstrated decreased functional network connectivity between the dorsal attention network (DAN) and posterior medial visual network (pmVN), between the SMN and pmVN, and between the SMN and lVN. Meanwhile, increased functional network connectivity was found between the lFPN and rFPN; however, there was no significant difference in functional network connectivity between VM patients and HCs. In addition, associations were found between clinical data and internetwork functional connectivity.

CONCLUSION

Functional connectivity between the lFPN and rFPN was reduced in patients with MwoA compared with HCs, which may indicate functional impairment in cognitive control, attention, somatosensory perception, and emotion regulation in patients with MwoA. VM patients showed decreased functional connectivity between the DAN, SMN, pmVN and lVN compared to patients with MwoA, which could account for the multisensory integration abnormalities and be the cause of vestibular symptoms in VM patients. These findings offer fresh perspectives on the pathophysiology of VM and MwoA.

"The Pupillary (Hippus) Nystagmus": A Possible Clinical Hallmark to Support the Diagnosis of Vestibular Migraine

(1) Background: Hippus (which in this paper will be called "Pupillary nystagmus") is a well-known phenomenon which has never been related to any specific pathology, so much so that it can be considered physiological even in the normal subject, and is characterized by cycles of dilation and narrowing of the pupil under constant lighting conditions. The aim of this study is to verify the presence of pupillary nystagmus in a series of patients suffering from vestibular migraine. (2) Methods: 30 patients with dizziness suffering from vestibular migraine (VM), diagnosed according to the international criteria, were evaluated for the presence of pupillary nystagmus and compared with the results obtained in a group of 50 patients complaining of dizziness that was not migraine-related. (3) Results: Among the 30 VM patients, only two cases were found to be negative for pupillary nystagmus. Among the 50 non-migraineurs dizzy patients, three had pupillary nystagmus, while the remaining 47 did not. This resulted in a test sensitivity of 0.93% and a specificity of 0.94%. (4) Conclusion: we propose the consideration of the presence of pupillary nystagmus as an objective sign (present in the inter-critical phase) to be associated with the international diagnostic criteria for the diagnosis of vestibular migraine.

Altered functional activity in the right superior temporal gyrus in patients with definite vestibular migraine

BACKGROUND

Vestibular migraine (VM) is one of the most common causes of episodic central vestibular disorders; it is worth investigating whether VM belongs to the migraine subtype or is a separate disorder. The study is aimed at investigating resting-state functional brain activity alterations in patients with definite VM (dVM).

METHODS

Seventeen patients with dVM, 8 patients with migraine, and 17 health controls (HCs) were recruited. The amplitude of low frequency fluctuation (ALFF), fractional ALFF (fALFF), and regional homogeneity (ReHo) were calculated to observe the changes in spontaneous brain activity.

RESULTS

Compared with HCs, VM patients showed significantly increased ALFF values in the right temporal lobe (P = 0.002) and increased ReHo values in the right superior, middle, and inferior temporal gyrus (STG, MTG, and ITG, P = 0.013); patients with migraine showed significantly increased ALFF values in the right limbic lobe (P = 0.04), left ITG (P = 0.024), and right frontal lobe (P < 0.001), significantly decreased ALFF values in the pons and brainstem (P = 0.013), and significantly decreased ReHo values in the frontal cortex (P < 0.001). Compared with patients with migraine, VM patients showed significantly increased fALFF values in the right parietal lobe (P = 0.011) and right frontal lobe (P = 0.026) and significantly increased ReHo values in the right thalamus (P = 0.043).

CONCLUSIONS

Patients with VM and migraine both had altered brain function, but the regions involved are different.

Vestibular Function and Clinical Presentation of Dizziness: Are They Similar in Patients With Different Types of Migraine?

OBJECTIVE

To compare the vestibular function and clinical aspects (vestibular and migraine symptoms) of patients divided into three groups-migraine without aura, migraine with aura, and chronic migraine-and a control group by using electronystagmography and a design questionnaire.

STUDY DESIGN

Case-control study.

SETTING

Tertiary referral center.

PATIENTS

Women aged between 18 and 55 years diagnosed with migraine with aura, migraine without aura, or chronic migraine according to the International Classification of Headache Disorders ICHD-third edition; diagnosis was made by a headache specialist. The control group consisted of patients' family members and hospital employees without a personal history of headache.

MAIN OUTCOME MEASURES

Application of a questionnaire regarding vestibular symptoms and their relation to migraine aspects. Assessment of the vestibular function by electronystagmography.

RESULTS

This study evaluated 120 female patients. Dizziness was the most prevalent vestibular symptom in all the migraine groups, with higher prevalence in the episodic migraine with aura and chronic migraine groups. Phonophobia and photophobia during vestibular symptoms also had greater prevalence in the latter groups. Electronystagmography tests did not reveal differences among the groups, but clinical stratification showed that tests with mixed etiology abnormalities were more prevalent in the episodic migraine with aura and chronic migraine groups.

CONCLUSION

The prevalence of vestibular symptoms in the migraine groups and the etiology of vestibular impairment highlight that migraine affects the vestibular system. Our findings suggest that symptom progression and vestibular impact are related to migraine chronicity and presence of aura.

Sensory organization of balance control in children with vestibular migraine and recurrent vertigo of childhood

Background

Migraine plays an important role in some subgroups of children with recurrent vertigo. Moreover, the migraine component varies from definite to possibly absent as defined in this spectrum of three disorders—vestibular migraine of childhood (VMC), probable VMC (pVMC), and recurrent vertigo of childhood (RVC). However, studies on the sensory organization of balance control in these three disorders are rare.

Objective

To explore the balance control of children with RVC, VMC, and pVMC, when the three sensory systems are challenged.

Method

A retrospective analysis was performed on 125 children with VMC (18 female and 15 male; aged 11.64 ± 2.74), pVMC (10 female and eight male; aged 11.78 ± 2.51), and RVC (32 female and 42 male; aged 11.10 ± 2.60). All children in each subtype were divided into groups of children aged ≤ 12 years old and 13–17 years old. Vestibular examination screening and assessment for postural control using the six conditions of the sensory organization test (SOT) were performed. The three primary outcome measures were: equilibrium score (ES), strategy score (SS), and sensory analysis score of the SOT.

Results

Equilibrium score under six different conditions and composite score increased with age (all P-values &lt; 0.05). The somatosensory and visual scores also improved with growing (P-values &lt; 0.05). However, vestibular scores did not increase significantly with age as the other senses did (P &gt; 0.05). In the children ≤ 12 year-old group, children with VMC had a significantly higher visual preference score than those with pVMC and RVC (P &lt; 0.05). There was an effect of age on the horizontal HIT. Ocular vestibular evoked myogenic potential (oVEMP), cervical vestibular evoked myogenic potential (cVEMP), and unilateral weakness (UW) values showed no significant difference among three diseases.

Conclusion

Compared with patients at the age of 13–17 years old and with RVC and pVMC (both ≤ 12 years old), children with VMC had a higher degree of reliance on visual signals to maintain their balance and a poorer central integration of peripheral information before reaching 12 years of age. In addition, vision may predominate by weakening vestibular function based on visuo-vestibular interactions. It must be noted that peripheral vestibular examinations could not distinguish the three disease subtypes.

Evaluation of video head impulse test during vertiginous attack in vestibular migraine

Objective

The aim of this study is to evaluate vestibular functions with video head impulse test (VHIT) and to understand the value of VHIT in differential diagnosis in patients with vestibular migraine (VM) during dizziness attack.

Materials and methods

Two groups were enrolled in this study. The first consisted of 84 vestibular migraine patients, and second group of 74 healthy subjects. VHIT was applied to patients with VM during vertigo attack and the results were compared with the VHIT values applied to subjects in the control group.

Results

The mean vestibulo-ocular reflex (VOR) in all semicircular canals in the VM group was lower than healthy individuals, but the results were not statistically significant. Refixation saccades were found in 52.3% of VM patients and in 10.2% of healthy individuals.

Conclusions

When patients with VM were evaluated with VHIT during vertiginous attack, VOR gain values were not different from healthy individuals, but the number of catch-up saccades were higher in VM patients, which indicates peripheral vestibular involvement. For differential diagnosis in patients with VM, vestibular tests should be performed during the vertigo attack. When evaluating VHIT results, the presence of refixation saccades should also be evaluated.

Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit

Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.

The Role of the Functional Head Impulse Test with and without Optokinetic Stimuli in Vestibular Migraine and Acute Unilateral Vestibulopathy: Discovering a Dynamic Visual Dependence

(1) Background: Visually induced vertigo (i.e., vertigo provoked by moving visual scenes) can be considered a noticeable feature of vestibular migraines (VM) and can be present in patients suffering from acute unilateral vestibulopathy (AUV). Hypersensitivity to moving or conflicting visual stimulation is named visual dependence. (2) Methods: Visuo-vestibular interactions were analyzed via the functional Head Impulse Test (fHIT) with and without optokinetic stimulation (o-fHIT) in 25 patients with VM, in 20 subjects affected by AUV, and in 20 healthy subjects. We calculated the percentage of correct answers (%CA) without and with the addition of the optokinetic background (OB). (3) In VM groups, the %CA on the fHIT was 92.07% without OB and 73.66% with OB. A significant difference was found between %CA on the deficit side and that on the normal side in AUV, both without OB and with OB. (4) Conclusions: The fHIT results in terms of %CA with and without OB could be useful to identify the presence of a dynamic visual dependence, especially in patients suffering from VM. The difference in %CA with and without OB could provide instrumental support to help correctly identify subjects suffering from VM. We propose the use of the fHIT in clinical practice whenever there is a need to highlight a condition of dynamic visual dependence.

Measuring threshold and latency of motion perception on a swinging bed

INTRODUCTION

Our objective was to develop and to evaluate a system to measure latency and threshold of pendular motion perception based on a swinging bed.

MATERIALS AND METHODS

This prospective study included 30 healthy adults (age: 32 ± 12 years). All subjects were tested twice with a 10 min. interval. A second trial was conducted 2 to 15 days after. A rehabilitation swinging bed was connected to an electronic device emitting a beep at the beginning of each oscillation phase with an adjustable time lag. Subjects were blindfolded and auditory cues other than the beep were minimized. The acceleration threshold was measured by letting the bed oscillate freely until a natural break and asking the patient when he did not perceive any motion. The perception latency was determined by asking the patient to indicate whether the beep and the peak of each oscillation were synchronous. The time lag between sound and peak of the head position was swept from -750 to +750 ms by 50 ms increments.

RESULTS

The mean acceleration threshold was 9.2±4.60 cm/s2. The range width of the synchronous perception interval was estimated as 535±190 ms. The point of subjective synchronicity defined as the center of this interval was -195±106 ms (n = 30). The test-retest evaluation in the same trial showed an acceptable reproducibility for the acceleration threshold and good to excellent for all parameters related to sound-movement latency.

CONCLUSION

Swinging bed combined to sound stimulation can provide reproducible information on movement perception in a simple and non-invasive manner with highly reproducible results.

The clinical significance of fHIT in migraine patient without vertigo symptom

OBJECTIVE

The aim of this study was to assess the functional head impulse test on migraine patients without vertigo. fHIT is a new vestibular test which evaluates the ability to see and read clearly during head movement as a functional measurement of the vestibulo-ocular reflex.

MATERIALS AND METHODS

The study included 20 patients suffering from migraine without vertigo between the ages of 20 and 30-years-old who were diagnosed by a neurologist and 20 individuals with non-migraine headaches (control group), with similar demographic characteristics. The functional head impulse test was applied to both groups, and the migraine disability assessment test was applied to migraine patients.

RESULTS

There was no statistically significant difference in the general fHIT results between the migraine group and the control group (p > 0.05). However, a statistically significant decrease was obtained in migraine patients in the left lateral (p = 0.018) and right posterior (p = 0.029) semicircular canals at 4000 Hz and the right anterior semicircular canal at 6000 Hz (p = 0.019). When compared by the degree of migraine disability assessment test, no significant difference in the fHIT results were observed (p > 0.05).

CONCLUSION

The semicircular canals may be affected at high head acceleration (4000-6000 Hz) in migraine patients without a history of vertigo. It should be considered that fHIT results between 4000 and 6000 Hz in migraine patients without vertigo can be pathologic.

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.