Vestibular Migraine: Cognitive Dysfunction, Mobility, Falls

Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI) : A narrative review

BACKGROUND

Vestibular migraine (VM) has a wide range of clinical presentations that can have a significant negative impact on quality of life. Currently, there is no objective test available to confirm the diagnosis or measure the severity of VM. The only available tools for assessing disease severity are patient-reported outcome measures (PROMs), such as the Dizziness Handicap Inventory (DHI).

OBJECTIVE

This manuscript aims to summarize the current knowledge about a newly developed PROM called the Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI).

METHODS

A comprehensive search was conducted across the Web of Science, Scopus, PubMed, and Google Scholar databases up to February 2024, using the keywords "Vestibular migraine," "VM-PATHI," and "Patient-Reported Outcome Measure." Only studies involving human participants were included, and no additional restrictions were applied. The reference lists of included studies were also reviewed to identify other eligible studies. The main outcome of interest was the evaluation of VM-PATHI in patients with VM.

RESULTS

The VM-PATHI is a 25-item questionnaire divided into six sections: headache equivalents, motion sensitivity, anxiety, cognition, disequilibrium/central audiovestibular disturbance, and emotion/sense of being overwhelmed. This tool has demonstrated good face and content validity, discriminant validity, responsiveness, test-retest reliability, and internal reliability (Cronbach's α: 0.92). Patients with VM are likely to show clinical improvement in symptoms if their VM-PATHI scores decrease by ≥6 points. Additionally, VM-PATHI has shown a good correlation with clinical improvement across various treatment modalities.

CONCLUSION

The VM-PATHI may provide advantages over other PROMs by measuring a wider spectrum of disease-specific effects of VM. Scores are correlated with the DHI, dizzy days per month, and other quality of life metrics.

Why is vestibular migraine associated with many comorbidities?

Vestibular migraine (VM) is a usual trigger of episodic vertigo. Patients with VM often experience spinning, shaking, or unsteady sensations, which are usually also accompanied by photophobia, phonophobia, motor intolerance, and more. VM is often associated with a number of comorbidities. Recurrent episodes of VM can affect the patient's emotions, sleep, and cognitive functioning to varying degrees. Patients with VM may be accompanied by adverse moods such as anxiety, fear, and depression, which can gradually develop into anxiety disorders or depressive disorders. Sleep disorders are also a common concomitant symptom of VM, which significantly lower patients' quality of life. The influence of anxiety disorders and sleep disorders may reduce cognitive functions of VM, such as visuospatial ability, attention, and memory decline. Clinically, it is also common to see VM comorbid with other vestibular disorders, making the diagnosis more difficult. VM episodes are relieved but lingering, in which case VM may coexist with persistent postural-perceptual dizziness (PPPD). Anxiety may be an important bridge between recurrent VM and PPPD. The clinical manifestations of VM and Meniere's disease (MD) overlap considerably, and those who meet the diagnostic criteria for both can be said to have VM/MD comorbidity. VM can also present with positional vertigo, and some patients with VM present with typical benign paroxysmal positional vertigo (BPPV) nystagmus on positional testing. In this paper, we synthesize and analyze the pathomechanisms of VM comorbidity by reviewing the literature. The results show that it may be related to the extensive connectivity of the vestibular system with different brain regions and the close connection of the trigeminovascular system with the periphery of the vestibule. Therefore, it is necessary to pay attention to the diagnosis of comorbidities in VM, synthesize its pathogenesis, and give comprehensive treatment to patients.

Association of Vestibular Disorders and Cognitive Function: A Systematic Review

OBJECTIVES

The purpose of this study is to consolidate and condense the available evidence about the potential association between vestibular diseases and cognitive impairment.

DATA SOURCES AND METHODS

A systematic search was conducted on four English databases (PubMed, Embase, Web of Science, Cochrane Library) from the time of library construction to March 2024. The study incorporated various keywords such as "vestibular disorders," "vertigo," "dizziness," "Meniere's disease," "benign paroxysmal positional vertigo," "vestibular migraine," "vestibular neuritis," "labyrinthitis," "bilateral vestibular disease," as well as "cognitive function" and "cognitive dysfunction." A qualitative review was conducted to look for and assess pertinent studies.

RESULTS

A total of 45 publications were incorporated, encompassing prevalent vestibular disorders, mostly targeting individuals in the middle-aged and older demographic. The findings indicate that individuals with vestibular disorders experience varying levels of cognitive impairment, which is evident in different aspects, with visuospatial cognitive deficits being more prominent. Furthermore, patients with chronic vestibular syndromes are more prone to cognitive dysfunction. Lastly, the hippocampus plays a crucial role in the intricate vestibular neural network.

CONCLUSION

The findings of this comprehensive review indicate that vestibular disorders can result in impairments across various aspects of cognitive functioning, particularly in visuospatial cognition. The underlying mechanism may be associated with a decrease in the size of the hippocampus. Individuals suffering from chronic vestibular dysfunction exhibit a higher likelihood of experiencing cognitive deficits.

LEVEL OF EVIDENCE

NA Laryngoscope, 134:4858-4872, 2024.

A placebo controlled, randomized clinical trial of galcanezumab for vestibular migraine: The INVESTMENT study

OBJECTIVE

To study if galcanezumab is effective for vestibular migraine (VM).

BACKGROUND

There are currently no placebo-controlled trials showing that treatment is effective for VM. Therefore, we performed the first placebo controlled, randomized clinical trial of a calcitonin gene-related peptide-targeted monoclonal antibody for VM.

METHODS

This was a single site, prospective, double-blind placebo controlled randomized clinical trial. Key inclusion criteria were as follows: participants aged 18-75 years with a diagnosis of VM or probable VM per Barany Society criteria. The primary outcome was change in VM-PATHI (Vestibular Migraine Patient Assessment Tool and Handicap Inventory) score, and secondary outcomes included change in DHI (Dizziness Handicap Inventory) score, and count of definite dizzy days (DDDs). Participants were randomized 1:1 to 3 months of treatment with galcanezumab or placebo via subcutaneous injection with a pre-filled syringe, 240 mg the first month, and 120 mg for the second and third months.

RESULTS

Forty participants were randomized, and 38 participants were in the modified intent to treat analysis. VM-PATHI score was reduced 5.1 points (95% confidence interval [CI] -13.0 to 2.7) for placebo (N = 21), and 14.8 points (95% CI -23.0 to -6.5) for galcanezumab (N = 17), a difference of -9.6 (95% CI -20.7 to 1.5, p = 0.044). DHI dropped 8.3 points in the placebo arm (95% CI -15.0 to 1.6), and 22.0 points in the galcanezumab arm (95% CI -31.9 to -12.1), a difference of -13.7 (95% CI -20.4 to -8.5, p = 0.018). The count of DDDs per month dropped from 18 days (standard deviation [SD] 7.6) in the baseline month to 12.5 days (SD 11.2) in month 4 for those in the placebo arm, and from 17.9 days (SD 7.9) in the baseline month to 6.6 days (SD 7.3) in month 4 for those in the galcanezumab arm, a difference of -5.7 days (95% CI -10.7 to -0.7, p = 0.026). No serious adverse events were observed.

CONCLUSIONS

In this pilot study, galcanezumab was effective in treating VM.

Anti-saccade as a tool to evaluate cognitive impairment in vestibular migraine

Background

Vestibular migraine (VM), an intricate subtype of migraine, amalgamates the dual attributes of migraine and vestibular disorders. In clinical settings, individuals with VM frequently articulate concerns regarding the manifestation of subjective cognitive impairment. This cognitive dysfunction is intricately linked with diminished mobility, heightened susceptibility to falls, and increased absenteeism in afflicted patients. Consequently, comprehending the features of cognitive impairment in VM patients holds potential clinical significance. The pursuit of rapid and objective methods for detection and assessment is foundational and prerequisite for efficacious cognitive management of VM patients.

Methods

The study encompassed 50 patients diagnosed with vestibular migraine and recruited 50 age-sex matched healthy controls. All participants underwent anti-saccade tasks, and cognitive evaluation was performed using the MMSE and MoCA to assess overall cognitive function. Additionally, RBANS scales were employed to measure specific cognitive domains.

Results

The VM patients and normal controls demonstrated statistical parity in terms of age, gender, education, weight, and BMI, with no significant differences observed. Analysis of cognitive scores divulged a marked increase in the incidence of Mild Cognitive Impairment (MCI) in VM patients compared to Healthy Controls (HCs). Both MMSE and MoCA scores were notably lower in VM patients compared to their healthy counterparts. The RBANS cognitive test indicated significant impairment in immediate memory, visuospatial construction, language, attention, and delayed memory among VM patients. Notably, the Trail Making Test and Stroop Color-Word Test revealed compromised processing speed and executive function cognitive domains. The anti-saccadic task highlighted significantly elevated anti-saccadic latency and frequency of direction errors in vestibular migraine patients. Symptom severity, illness duration, and episode frequency in VM patients positively correlated with counter-scanning errors and negatively correlated with cognitive performance across diverse cognitive domains.

Conclusion

VM patients exhibit cognitive decline across multiple cognitive domains during the interictal period. This cognitive impairment may not be fully reversible, underscoring its potential clinical significance for cognitive management in VM patients. The sensitivity of anti-saccade tasks to the cognitive status of VM patients positions them as promising objective indicators for diagnosis, intervention, and evaluation of cognitive impairment effects in VM in future applications.

Cognition in vestibular disorders: state of the field, challenges, and priorities for the future

Vestibular disorders are prevalent and debilitating conditions of the inner ear and brain which affect balance, coordination, and the integration of multisensory inputs. A growing body of research has linked vestibular disorders to cognitive problems, most notably attention, visuospatial perception, spatial memory, and executive function. However, the mechanistic bases of these cognitive sequelae remain poorly defined, and there is a gap between our theoretical understanding of vestibular cognitive dysfunction, and how best to identify and manage this within clinical practice. This article takes stock of these shortcomings and provides recommendations and priorities for healthcare professionals who assess and treat vestibular disorders, and for researchers developing cognitive models and rehabilitation interventions. We highlight the importance of multidisciplinary collaboration for developing and evaluating clinically relevant theoretical models of vestibular cognition, to advance research and treatment.

Correlating Vestibular Migraine Patient Assessment Tool and Handicap Inventory to Daily Dizziness Symptoms

OBJECTIVE

Investigate the relationship between Vestibular Migraine Patient Assessment Tool and Handicap Inventory (VM-PATHI) scores and daily dizziness symptoms.

STUDY DESIGN

Prospective cohort analysis of 52 patients with vestibular migraine (VM).

SETTING

Tertiary referral center.

PATIENTS

Fifty-two patients diagnosed with VM or probable VM according to Barany Society criteria.

INTERVENTIONS

Subjects reported their dizzy symptoms (on a scale of 0 [no symptoms], 1 [mild], 2 [moderate], and 3 [severe]) every day for 1 month via automated text messaging linked to a cloud-based research database. Subjects completed VM-PATHI and Dizziness Handicap Inventory (DHI) scores at the end of the month. We examined the correlation between a composite of daily dizziness scores with VM-PATHI and DHI scores through linear regression and correlation analysis.

MAIN OUTCOME MEASURES

Pearson correlation coefficient, R2 value.

RESULTS

VM-PATHI showed a moderate correlation with daily dizziness symptoms (correlation coefficient, 0.51). DHI showed a lower correlation with daily dizziness (correlation coefficient, 0.38). VM-PATHI score was a strong predictor of daily dizziness with univariate linear regression ( R2 = 0.26, p = 0.001). In a multiple linear regression model with age, history of anxiety and/or depression, and VM-PATHI, the VM-PATHI score was the only statistically significant predictor of daily dizziness ( p < 0.001).

CONCLUSIONS

Daily dizziness symptoms are better correlated with VM-PATHI score than the DHI, providing further validation of VM-PATHI as a disease-specific outcome measure for patients with VM.

Spinning Through History: Evolution of the Concept of Vestibular Migraine

Vestibular migraine represents a growing public health problem, imposing enormous societal burdens in the form of patient suffering, loss of productivity, and direct healthcare costs. This raises the question of how we developed our ideas about vestibular migraine and how these ideas shape how we treat it. This review walks through the history of how our conceptualization of migraine and vestibular symptoms evolved, starting with clinical observations in ancient times, inclusion under the umbrella of Meniere's disease, and then separation from Meniere's disease with its own identity. Tradition, clinical observations, and diagnostic criteria developed by professional societies have played prominent roles in building our current concept of vestibular migraine. A review of the ideas that have shaped our current conception of vestibular migraine may help us to see which ones have stood the test of time and which ones should continue to evolve. As in other disciplines, we study history in medicine to be inspired, warned, and sometimes, to be freed.

Migraine management for the otolaryngologist

Objective

To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.

Methods

Narrative review of available literature.

Results

Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.

Conclusion

Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.