An epidemiological study to investigate the relationship between Meniere's disease and migraine

Mendelian randomization analysis does not reveal a causal association between migraine and Meniere's disease

Background

According to observational research, migraine may increase the risk of Meniere's disease (MD). The two have not, however, been proven to be causally related.

Methods

Using Mendelian random (MR) analysis, we aimed to evaluate any potential causal relationship between migraine and MD. We extracted single-nucleotide polymorphisms (SNPs) from large-scale genome-wide association studies (GWAS) involving European individuals, focusing on migraine and MD. The main technique used to evaluate effect estimates was inverse-variance weighting (IVW). To assess heterogeneity and pleiotropy, sensitivity analyses were carried out using weighted median, MR-Egger, simple mode, weighted mode, and MR-PRESSO.

Results

There was no discernible causative link between genetic vulnerability to MD and migraine. The migraine dose not increase the prevalence of MD in the random-effects IVW method (OR = 0.551, P = 0.825). The extra weighted median analysis (OR = 0.674, P = 0.909), MR-Egger (OR = 0.068, P = 0.806), Simple mode (OR = 0.170, P = 0.737), and Weighted mode (OR = 0.219, P= 0.760) all showed largely consistent results. The MD dose not increase the prevalence of migraine in the random-effects IVW method (OR = 0.999, P = 0.020). The extra weighted median analysis (OR = 0.999, P = 0.909), MR-Egger (OR = 0.999, P = 0.806), Simple mode (OR = 0.999, P = 0.737), and Weighted mode (OR = 1.000, P = 0.760).

Conclusion and significance

This Mendelian randomization study provides casual evidence that migraine is not a risk factor for MD and MD is also not a risk factor for migraine.

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.

Vestibular migraine or Meniere's disease: a diagnostic dilemma

Meniere's disease (MD) represents one of the vertigo disorders characterized by triad symptoms (recurrent vertigo, fluctuating hearing loss, tinnitus or ear fullness). The diagnosis of MD relies on the accurate and detailed taking of medical history, and the differentiation between MD and vestibular migraine (VM) is of critical importance from the perspective of the treatment efficacy. VM is a highly prevalent vertigo condition and its typical symptoms (headache, vestibular symptoms, cochlear symptoms) mimic those of MD. Furthermore, the misdiagnosis in MD and VM could lead to VM patients mistakenly receiving the traumatic treatment protocol designed for MD, and sustaining unnecessary damage to the inner ear. Fortunately, thanks to the advances in examination technologies, the barriers to their differentiation are being gradually removed. These advances enhance the diagnostic accuracy of vertigo diseases, especially VM and MD. This review focused on the differentiation of VM and MD, with an attempt to synthesize existing data on the relevant battery of differentiation diagnosis (covering core symptoms, auxiliary tests [audiometry, vestibular tests, endolymphatic hydrops tests]) and longitudinal follow-up. Since the two illnesses are overlapped in all aspects, no single test is sufficiently specific on its own, however, patterns containing all or at least some features boost specificity.

Characteristics of clinical details and endolymphatic hydrops in unilateral and bilateral Ménière's disease in a single Asian group

Objectives

To elucidate the characteristics of the clinical details and endolymphatic hydrops (EH) in bilateral Ménière's disease (BMD).

Methods

A total of 545 patients with definite MD were enrolled. Demographic variables; the age of onset; disease course; inner ear function; the coexistence of related disorders such as migraine, delayed MD, drop attacks, and autoimmune diseases; familial history; and characteristics of EH were analyzed.

Results

In the study population, the prevalence of BMD was 15.4%. The disease duration of BMD (84.0 ± 89.6 months) was significantly longer than that of unilateral MD (UMD, 60.1 ± 94.0 months) (P = 0.001). As evaluated by hearing thresholds and cervical and ocular vestibular evoked myogenic potentials, inner ear functions were more deteriorated in BMD (P < 0.05) than in UMD. The proportions of delayed MD and a family history of vertigo were significantly larger in BMD (P < 0.05). EH was observed in 100% of cases on the clinically affected side and 6.1% of cases on the unaffected side.

Conclusion

A low prevalence of BMD, longer disease duration, higher frequencies of delayed MD, and family history of vertigo in patients with BMD were significant findings observed in the present study. All affected ears presented with EH, and a low percentage of unaffected sides presented with EH.

A longitudinal study of unilateral Ménière's disease and clinical evolutionary models

OBJECTIVE

The heterogeneity of Ménière's disease is presently defined by a variety of subtypes. This study introduced three different subtypes of unilateral Ménière's disease based on the evolution of vertigo crises from their inception.

METHOD

A longitudinal descriptive study of 327 unilateral Ménière's disease patients was performed. In a subgroup of patients followed from the onset of the disease, 3 subtypes of unilateral Ménière's disease were defined according to the vertiginous crises suffered during the first 10 years of the disorder.

RESULTS

Data was available for 87 patients with unilateral Ménière's disease from the start of their disease (26.6 per cent of the original sample). These patients were grouped into three models according to their symptomatic evolution. Model 3 was associated with a worse hearing prognosis, a greater number of Tumarkin's otolithic crises and the need for surgery. Model 1 presented less hearing loss.

CONCLUSION

Unilateral Ménière's disease models based on the evolution of vertiginous crises present differences according to aspects such as hearing loss, vertiginous crisis, Tumarkin's otolithic crisis and the need for surgery.

Ménière's disease: new guidelines, subtypes, imaging, and more

PURPOSE OF REVIEW

This article reviews recent developments in Ménière's disease including etiologic, diagnostic, and therapeutic investigations that have changed the landscape for medical providers. These updates shed light onto the complex nature of Ménière's disease and generate additional means to provide optimal care to patients.

RECENT FINDINGS

Given the multifactorial cause of Ménière's disease, five subtypes of Ménière's disease have recently been proposed. A knowledge of these subtypes will aid in the development of an appropriate treatment algorithm. Although newer treatments have not been developed, stepwise treatment algorithms have been proposed and can improve patient care. New MRI modalities and serum testing hold promise as clinical clues and biomarkers.

SUMMARY

As these updated diagnostic criteria are used, Ménière's disease can be identified and treated more precisely. This will in turn allow for future randomized controlled studies to improve the quality of treatment options available. Future imaging, vestibular testing, and the potential for serum biomarkers may illuminate additional diagnostic criteria, only furthering the improvement in clinical care.

[Analysis of clinical characteristics of 87 patients with cochlear migraine]

Objective:The aim of this study is to analyze the clinical features of cochlear migraine. Methods:The clinical data of cases of cochlear migraine were collected, and the clinical symptoms and hearing examination results were analyzed. Results:The ratio of male to female patients with cochlear migraine was 1∶3.1; the peak incidence was between 30 to 60 years old; the clinical symptoms were tinnitus in 61 people（70%）, mild hearing loss in 52 people（60%）, aural fullness in hyperacusis in 13 people（15%）, auditory allergy in 9 people（10%） and otalgia in 5 people（6%）; the audiology characteristic was that 61.5%（32/52） of patients with hearing loss showed mild high-frequency neurological hearing loss, 34.6%（18/52） of patients showed mild low-frequency neurological hearing loss, and 3.8%（2/52） of patients showed full-frequency mild neurological hearing loss; the effective rate of tinnitus treatment was 57.4%, the effective rate of hearing loss was 71.2%, and the effective rate of aural fullness was 69.2%, the effective rate of hyperacusis is 66.7% and the effective rate of otalgia is 60.0%. Conclusion:The clinical characteristics of cochlear migraine are summarized, which provides a basis for the intervention of anti-migraine treatment programs for inner ear diseases.

Comparison of associated comorbid conditions in patients with benign paroxysmal positional vertigo with or without migraine history: A large single institution study

PURPOSE

In the largest reported United States (U.S.) cohort of benign paroxysmal positional vertigo (BPPV), does the presence or absence of migraine correlate with increased associations of other factors?

MATERIALS & METHODS

A retrospective chart review from a single U.S. neurotology center. Adult patients with BPPV from 2003 to 2017 classified into two groups: 1) with migraine; 2) without migraine.

RESULTS

The prevalence of self-reported migraine history in a BPPV-positive population (n = 1481) was 25.8% (n = 382). Among those with BPPV and migraine, 88.5% were female, 8.1% had diabetes, 22.5% had prior history of BPPV, 8.9% had Meniere's disease and recurrence rate was 38.3%. No statistically significant differences between recurrence or resolution rates between the two groups were demonstrated (p > 0.05). Adjusted logistic regression model found that women and those with a prior history of BPPV had significantly higher odds of having both BPPV and migraine conditions compared to their counterparts. In contrast, older age and diabetes were associated with significantly lower odds of concomitant BPPV and migraine.

CONCLUSIONS

The prevalence of migraine among the study sample was 25.8%. Female gender, prior history of BPPV, younger age, and lack of diabetes were independently associated with the concurrent comorbidity of BPPV and migraine. These data further substantiate previously reported rates (from smaller studies); and, demonstrate that recurrence and resolution rates are not worse in those with BPPV and migraine compared to the general BPPV population. Findings support an association between migraine and BPPV and enhances one's ability to accurately counsel patients regarding these diseases.

Phonophobia and migraine features in patients with definite meniere's disease: Pentad or triad/tetrad?

Background: Epidemiological studies have shown different association between migraine and Meniere's disease (MD). Few studies investigated the frequency of phonophobia in MD.Objectives: This study aimed to determine the frequency of phonophobia and other features of migraine in definite MD.Material and Methods: Patients with definite MD and a group of healthy (non-MD, non-vertiginous) control subjects participated. Demographic data and other clinical features of the two diseases recorded. Data analyzed in SPSS software version 20, by qi square and independent T test and logistic regression model.Results: 69 MD patients (average age: 48.87 ± 12.15 years) and 60 control subjects (average age: 47.58 ± 12.05 years) enrolled. The frequency of migraine headache in MD cases was 16% (45% with aura) compared with 5% in control group (three cases; 2 without and 1 with aura) (p < .001). Family history of migraine was the only determinant of the presence of migraine in MD (p = .001, OR = 15.625, 95%CI: 2.94-88.33). The frequency of phonophobia in MD was very high (88.4%: 54.5% in migraine subgroup and 89.6% in non-migraine cases) and without significant relation to existence of migraine, in contrast to photophobia and osmophobia (p = .064).Conclusions: The frequency of migraine in MD is higher than normal subjects. Phonophobia may be an independent symptom in MD.

Head-Shaking Nystagmus in the Early Stage of Unilateral Meniere's Disease

OBJECTIVES

The aim of the present study was to evaluate the ability of head-shaking nystagmus (HSNy), evoked after the resolution of a vertigo spell, to predict an imminent crisis in the early stage of Meniere's disease (MD).

MATERIALS AND METHODS

A total of 20 patients in the early stage of MD were included in the study. The head-shaking test (HST) was performed twice, during the first visit within 24 h of vertigo spell (T0) and 48 h later (T1). The onset of a new vertigo episode during the 2 weeks following the first visit was recorded in each patient's medical record. The sensitivity and specificity of HSNy toward predicting a new vertigo episode were calculated.

RESULTS

At T0, an evoked ipsilesional HSNy in 15 (75%) patients was observed; in four of them, the HSNy had a biphasic component. The HSNy was present and persistent at T1 in 8 (42.1%) patients; among these cases, 6 patients had ipsilesional HSNy, and 2 patients a contralesional HSNy. None of the patients presented with a biphasic HSNy at T1. Seven (36.8%) patients experienced the recurrence of a vertigo crisis. Among these, 6 patients had ipsilesional HSNy at T1. Only 8 patients with ipsilesional HSNy at T0 did not have recurrence. The sensitivity of the ipsilesional HSNy in predicting the recurrence of vertigo in patients with MD was 100% at T0 and 85.7% at T1. The specificity was 46.6% and 100% at T0 and T1, respectively.

CONCLUSION

The HST can be a useful test in the early stages of MD to predict a new vertigo attack.

Bidirectional analysis of the association between Ménière's disease and depression: Two longitudinal follow-up studies using a national sample cohort

OBJECTIVE

This study aimed to delineate the causal relationship between Ménière's disease and depression.

DESIGN

Two longitudinal follow-up studies.

MAIN OUTCOME MEASURES

The 2002-2013 Korean National Health Insurance Service-Health Screening Cohort was used. In study I, Ménière's disease patients were 1:4 matched with the control I group for age group, sex, income group and region of residence, and the occurrence of depression was observed. In study II, the depression patients were 1:4 matched with the control II group for the same variables, and the occurrence of Ménière's disease was observed. The stratified Cox proportional hazard model was used. Subgroup analyses were performed according to age and sex.

RESULTS

In study I, 6.9% (420/6044) of the Ménière's disease patients and 3.7% (885/24 176) of the control I participants experienced depression. The adjusted hazard ratio (HR) of Ménière's disease for depression was 1.94 (95% confidence intervals [CI] = 1.73-2.18, P < .001). In study II, 1.6% (490/31 649) of the depression patients and 1.0% (1240/126 596) of the control II participants were diagnosed with Ménière's disease. The adjusted HR of depression for Ménière's disease was 1.58 (95% CI = 1.43-1.76, P < .001). All age and sex subgroups demonstrated higher HRs of Ménière's disease for depression (study I) and depression for Ménière's disease (study II).

CONCLUSION

Ménière's disease patients showed an increased likelihood of depression. Conversely, depression patients showed an elevated likelihood of Ménière's disease.

Depression in Ménière's disease: a systematic review and meta-analysis

Background

Ménière's disease is a debilitating chronic peripheral vestibular disorder associated with psychiatric co-morbidities, notably depression.

Methods

Database searches were performed to identify studies that assessed depression in Ménière's disease. Metrics used to diagnose depression were extracted, along with the prevalence of depression in each study.

Results

Fifteen studies from 8 different countries reported on 6587 patients. The weighted average age was 55.3 years (range, 21–88 years). Depression was measured by eight different scales, with Zung's Self-Rating Depression Scale used most often. A weighted proportion of 45.9 per cent of patients (confidence interval = 28.9–63.3) were depressed. Weighted averages (± standard deviations) of Beck's Depression Inventory and the Illness Behavior Questionnaire – Dysphoria were 8.5 ± 7.9 and 2.4 ± 1.7, respectively.

Conclusion

The prevalence of depression in patients with Ménière's disease is nearly 50 per cent. Treating otolaryngologists should have a low threshold to screen and refer appropriately. Identifying and treating depression should allow for improvement of overall quality of life in patients with Ménière's disease.

Self-motion perception is sensitized in vestibular migraine: pathophysiologic and clinical implications

Vestibular migraine (VM) is the most common cause of spontaneous vertigo but remains poorly understood. We investigated the hypothesis that central vestibular pathways are sensitized in VM by measuring self-motion perceptual thresholds in patients and control subjects and by characterizing the vestibulo-ocular reflex (VOR) and vestibular and headache symptom severity. VM patients were abnormally sensitive to roll tilt, which co-modulates semicircular canal and otolith organ activity, but not to motions that activate the canals or otolith organs in isolation, implying sensitization of canal-otolith integration. When tilt thresholds were considered together with vestibular symptom severity or VOR dynamics, VM patients segregated into two clusters. Thresholds in one cluster correlated positively with symptoms and with the VOR time constant; thresholds in the second cluster were uniformly low and independent of symptoms and the time constant. The VM threshold abnormality showed a frequency-dependence that paralleled the brain stem velocity storage mechanism. These results support a pathogenic model where vestibular symptoms emanate from the vestibular nuclei, which are sensitized by migraine-related brainstem regions and simultaneously suppressed by inhibitory feedback from the cerebellar nodulus and uvula, the site of canal-otolith integration. This conceptual framework elucidates VM pathophysiology and could potentially facilitate its diagnosis and treatment.

Differential Proinflammatory Signature in Vestibular Migraine and Meniere Disease

Vestibular Migraine (VM) and Meniere's Disease (MD) are episodic vestibular syndromes defined by a set of associated symptoms such as tinnitus, hearing loss or migraine features during the attacks. Both conditions may show symptom overlap and there is no biological marker to distinguish them. Two subgroups of MD patients have been reported, according to their IL-1β profile. Therefore, considering the clinical similarity between VM and MD, we aimed to investigate the cytokine profile of MD and VM as a means to distinguish these patients. We have also carried out gene expression microarrays and measured the levels of 14 cytokines and 11 chemokines in 129 MD patients, 82 VM patients, and 66 healthy controls. Gene expression profile in peripheral blood mononuclear cells (PBMC) showed significant differences in MD patients with high and low basal levels of IL- 1β and VM patients. MD patients with high basal levels of IL- 1β (MDH) had overall higher levels of cytokines/chemokines when compared to the other subsets. CCL4 levels were significantly different between MDH, MD with low basal levels of IL- 1β (MDL), VM and controls. Logistic regression identified IL- 1β, CCL3, CCL22, and CXCL1 levels as capable of differentiating VM patients from MD patients (area under the curve = 0.995), suggesting a high diagnostic value in patients with symptoms overlap.

Dizziness Handicap and Its Contributing Factors in Patients With Migraine

OBJECTIVE

Dizziness is frequently reported in patients with migraine. However, its assessment is often neglected in clinical practice. We investigated the dizziness handicap experienced by patients with migraine and its contributing factors.

METHODS

A total of 361 migraine outpatients (270 women, 91 men; mean age 39.01 ± 11.2 years) were given the Korean Dizziness Handicap Inventory (KDHI) questionnaire (total score: 100 points; cutoff: 29). The Headache Impact Test, Generalized Anxiety Disorder-7, Patient Health Questionnaire-9, and Pittsburgh Sleep Quality Index were also administered. Clinical data such as age, sex, number of headache attacks per month, pain intensity on the visual analog scale, and average sleep hours were collected to find contributing factors. Comparisons were made between chronic and episodic migraine.

RESULTS

A total of 153 patients were classified as having dizziness handicap (M+DH) and 208 had migraine without dizziness handicap (M-DH). Patients with M+DH experienced more headache attacks per month than patients with M-DH (P = 0.010). The proportion of patients with chronic migraine was larger in the M+DH group (29.4% vs. 17.3%, P = 0.006). Patients with M+DH showed higher scores than patients with M-DH in all the KDHI subscales. Multivariable logistic regression showed headache impact, pain intensity, anxiety, and depression to be significantly associated with dizziness handicap.

CONCLUSION

The data suggest that patients with migraine, especially those with chronic-type migraine, experience physical, emotional, and functional handicaps due to dizziness. Dizziness handicap is related to headache impact, anxiety, and depression. Targeted management of such factors is required to reduce the severity of subjective discomfort.

Clinical Features and Endolymphatic Hydrops in Patients With MRI Evidence of Hydrops

OBJECTIVES:

The purpose of this study was to investigate the correlation between grades of endolymphatic hydrops (ELH) and clinical characteristics and determine the detailed clinical characteristics of Ménière's disease (MD) patients with evidence of hydrops based on magnetic resonance imaging (MRI).

METHODS:

One hundred ninety-eight MD patients (396 ears) with MRI evidence of hydrops were included. ELH grades were evaluated using the Nakashima grading standard. Correlations between the extent of ELH and clinical features were evaluated. Detailed clinical characteristics were analyzed to assess the clinical diagnostic criteria.

RESULTS:

Of 198 patients, ELH was observed in 100% of cases on the clinically affected side and 8.6% of cases on the asymptomatic side. In addition, 98.5% of ELH was classified as moderate or significant grade. Low-frequency hearing loss was significantly correlated with the extent of both vestibular and cochlear hydrops, whereas the vertigo attack frequency showed no significant correlation with ELH grades. The disease duration of MD with bilateral ELH was longer than that with unilateral ELH. The clinical characteristics were variant and did not completely fit the proposed diagnostic criteria.

CONCLUSIONS:

MRI findings have relevance to the clinical severity, to a certain extent, but not vestibular symptoms. The proposed diagnostic criteria based on clinical characteristics may be partially effective; analysis of the detailed clinical characteristics of MD was meaningful. Diagnosis of MD based on both MRI and clinical symptoms could facilitate an early diagnosis.

Stress and Unusual Events Exacerbate Symptoms in Menière's Disease: A Longitudinal Study

HYPOTHESIS

Stress and unusual events are associated with a higher likelihood of attacks and increased symptom severity in Menière's disease (MD).

BACKGROUND

MD is an unpredictable condition which severely impacts the quality of life of those affected. It is thought that unusual activity and stress may act as an attack trigger in MD, but research in this area has been limited to date.

METHODS

This was a longitudinal study conducted over two phases. A mobile phone application was used to collect daily data on Menière's attacks and individual symptoms (aural fullness, dizziness, hearing loss, and tinnitus), as well as prevalence of unusual events (phase I), and stress levels (phase II). There were 1,031 participants (730 women, mean age 46.0 yr) in phase I and 695 participants (484 women, mean age 47.7 yr) in phase II. Panel data regression analyses were employed to examine for associations between unusual events/stress and attacks/symptoms, including the study of 24 hours lead and lag effects.

RESULTS

Unusual events and higher stress levels were associated with higher odds of Menière's attacks and more severe symptoms. The odds of experiencing an attack were 2.94 (95% confidence interval [CI] 2.37, 3.65) with reporting of unusual events and increased by 1.24 (95% CI 1.20, 1.28) per unit increase in stress level. Twenty-four hour lead (OR 1.10 [95% CI 1.07, 1.14]) and lag (OR 1.10 [95% CI 1.06, 1.13]) effects on attacks were also found with increases in stress.

CONCLUSION

This study provides the strongest evidence to date that stress and unusual events are associated with attacks and symptom exacerbation in MD. Improving our understanding of stress and unusual events as triggers in Menière's may reduce the uncertainty associated with this condition and lead to improved quality of life for affected individuals.

Population-Based Study on the Epidemiology of Ménière's Disease

BACKGROUND AND OBJECTIVE

Ménière's disease (MD) is a disorder of the inner ear typically showing recurrent acute episodes of vertigo, hearing loss, and tinnitus. Epidemiologic studies on MD are scarce. We assessed the incidence rates (IRs) of MD and describe the characteristics of MD cases, comparing them to control patients without recorded evidence of MD.

STUDY DESIGN

We conducted a retrospective population-based follow-up study and a nested case-control analysis using data from the UK-based Clinical Practice Research Datalink.

METHODS

We identified patients between 18 and 79 years of age with an incident MD diagnosis between January 1993 and December 2014. We assessed the IRs of betahistine-treated MD. In the nested case-control analysis, we matched 4 controls to each MD case on sex, age, general practice, years of active history in the database, and calendar time. We conducted a χ2 test to present p values in order to compare the prevalence of demographics, comorbidities, and co-medication between cases and controls.

RESULTS

We identified 5,508 MD cases and 22,032 MD-free controls (65.4% females). The overall IR for MD in the UK was 13.1 per 100,000 person-years. More cases were female, and the mean age at diagnosis was 55.4 ± 13.7 years. Smoking and alcohol consumption were less prevalent among MD cases. Depression, other affective disorders, sleeping disorders, anxiety, and migraine were more prevalent among MD cases than among controls.

CONCLUSIONS

MD is uncommon in primary care in the UK with a preponderance among females.

Meniere's, migraine, and motion sickness

CONCLUSION

Elevated Motion Sickness Susceptibility (MSS) in Meniere?s disease (MD) is likely to be a consequence of the onset of MD and not migraine per se.

OBJECTIVES

Pathologies of the vestibular system influence MSS. Bilateral vestibular deficits lower MSS, vestibular neuritis or benign paroxysmal positional vertigo have little overall effect, whereas vestibular migraine elevates MSS. However, less is known about MSS in MD, a condition in which many patients experience vestibular loss and migraine symptoms.

METHODS

The authors conducted an online survey that posed diagnostic and disease questions before addressing frequency of headaches, migraines, visual display dizziness (VDD), syncope, social life, and work impact of dizziness (SWID4) and motion sickness susceptibility (MSSQ). The two groups were: diagnosed MD individuals with hearing loss (n = 751) and non-MD individuals in the control group (n = 400).

RESULTS

The MD group showed significantly elevated MSS, more headache and migraine, increased VDD, higher SWID4 scores, and increased syncope. MSS was higher in MD than controls only after the development of MD, but not before, nor in childhood. Although elevated in MD compared with controls, MSS was lower than migraine patients from past data. Multivariate analysis revealed VDD, SWID4, and MSS in adulthood as the strongest predictors of MD, but not headache nor migraine.

Neuro-otology- some recent clinical advances

Vestibular disorders manifesting as vertigo, chronic dizziness and imbalance are common problems in neurological practice. Here, we review some recent interesting and important advances in diagnosis of vestibular disorders using the video head impulse test and in the management of benign positional vertigo and migrainous vertigo.