Influence of Migraine and of Migraine Aura on Balance and Mobility - A Controlled Study

Human RAMP1 overexpressing mice are resistant to migraine therapies for motion sensitivity: a mouse model of vestibular migraine

Both enhanced motion-induced nausea and increased static imbalance are \observed symptoms in migraine and especially vestibular migraine (VM). Motion-induced nausea and static imbalance were investigated in a mouse model, nestin/hRAMP1, expressing elevated levels of human RAMP1 in the CNS, which enhances CGRP signaling in the nervous system. Behavioral surrogates such as the motion-induced thermoregulation and postural sway center of pressure (CoP) assays were used to assess motion sensitivity. Tail vasodilation analysis revealed that this model exhibits an increased sensitivity to CGRP's effects at lower doses compared to control mice. In addition, the nestin/hRAMP1 mice exhibit a higher dynamic range in postural sway than their wildtype counterparts, along with increased sway observed in nestin/hRAMP1 male mice that was not present in male littermate controls. Results from migraine blocker experiments were challenging to interpret, but the data suggests that olcegepant is incapable of reversing CGRP-induced alterations in the nestin/hRAMP1 mice, while rizatriptan was ineffective in both the nestin/hRAMP1 and control mice. The results indicate that overexpression of hRAMP1 leads to heightened endogenous CGRP signaling. Results also suggest that both olcegepant and rizatriptan are ineffective in reducing CGRP-triggered nausea and sway in this hypersensitive CGRP mouse model. This study suggests that hypersensitivity to CGRP may be a mouse model for difficult to treat cases of vestibular migraine.

Balance alterations are associated with neck pain and neck muscle endurance in migraine

BACKGROUND

Migraine patients may present with both cervical and balance dysfunctions. The neck plays an important role in balance by providing substantial proprioceptive input, which is integrated in the central nervous system and influences the balance control systems. Whether balance and neck dysfunctions are associated in patients with migraine is still to be explored.

OBJECTIVES

This study aimed to assess the association between the sensory organization test of balance with neck pain features, cervical strength, endurance, and range of motion in patients with migraine.

METHODS

Sixty-five patients with migraine underwent the sensory organization test assessed with the Equitest-Neurocom® device. Maximum voluntary isometric contraction, cervical flexion and extension range of motion, and cervical flexor and extensor endurance were assessed. In addition, the features of migraine and neck pain were collected. Patients were dichotomized according to cut-off scores of balance performance and the association between outcomes were explored.

RESULTS

Patients with reduced balance performance presented a higher frequency of migraine (p = 0.035), a higher frequency of aura (p = 0.002), greater neck pain intensity (p = 0.013), and decreased endurance of cervical flexors (p = 0.010) and extensors (p < 0.0001). The total balance score was correlated with age (r = -0.33; p = 0.007), migraine frequency (r = -0.29; p = 0.021), neck pain intensity (r = -0.26; p = 0.038), and endurance of the cervical flexors (r = 0.39; p = 0.001) and extensors (r = 0.36; p = 0.001). Migraine frequency, neck pain intensity, and endurance of the cervical flexors can predict 21% of the sensory organization test variability.

CONCLUSION

Neck pain features and endurance of the cervical muscles are related to reduced balance performance in patients with migraine. These results shed light to a better understanding of balance alterations in migraine patients.

Balance disorders and migraine

BACKGROUND

Migraine is associated with motion sensitivity symptoms such as kinetosis, vestibular symptoms and balance alterations. While focus is given to headache management, addressing these symptoms is often neglected, although they are related to additional migraine burden and increased disability.

PURPOSE

Our aim is to disseminate the current understanding of the motion sensitivity symptoms among patients with migraine, with focus on balance impairments. We discuss the susceptibility of migraine to motion sensitivity, its suggested mechanisms, the balance alterations during quiet standing, mobility tasks and reactions to external perturbations. The role of migraine subdiagnosis, implications for clinical practice and future perspectives are also acknowledged.

IMPLICATIONS

Balance disorders are one of the signs reflecting a broader and complex spectrum of motion sensitivity, which are present even between attacks. Migraineurs are especially inherent to these symptoms probably due to brain hyperexcitability and to shared pathophysiological mechanisms. Patients, especially with aura and chronic migraine, exhibit balance instability during quiet standing under different surface and visual input conditions. Migraineurs demonstrated reduced limits of stability and lower performance on walk, transposing obstacles and sit to stand tasks. Only patients with aura present impairment of motor control reactions following external perturbations. Balance alterations are associated with falls and are influenced by aura, migraine frequency and psychosocial aspects, but not by vestibular symptoms or vestibular migraine diagnosis. There is a high demand for high quality of evidence regarding the assessment and care of motion sensitivity symptoms in migraineurs, considering approaches to manage not just the pain, but its associated symptoms.

Impairments to the multisensory integration brain regions during migraine chronification: correlation with the vestibular dysfunction

Objectives

Migraine is often combined with vestibular dysfunction, particularly in patients with chronic migraine (CM). However, the pathogenesis of migraine chronification leading to vestibular dysfunction is not fully understood. The current study investigated whether structural or functional impairments to the brain during migraine chronification could be associated with vestibular dysfunction development.

Methods

The eligible participants underwent clinical assessment and magnetic resonance imaging (MRI) scans. Voxel-based morphometry (VBM) determined structural impairment by evaluating alterations in gray matter volume (GMV). Functional impairment was assessed by the mean amplitude of low-frequency fluctuation (mALFF). Furthermore, the resting-state functional connectivity (rsFC) of regions possessing impairment was examined with a seed-based approach. We also analyzed the correlations between altered neuroimaging features with clinical variables and performed multiple linear regression.

Results

Eighteen CM patients, 18 episodic migraine (EM) patients, and 18 healthy controls (HCs) were included in this study. A one-way ANOVA indicated the group differences in mALFF. These were located within right supramarginal gyrus (SMG), left angular gyrus (AG), middle frontal gyrus (MFG), left middle occipital gyrus (MOG), right rolandic operculum (Rol) and left superior parietal gyrus (SPG). During rsFC analysis, the CM group had more enhanced rsFC of left SPG with left MOG than the EM and HC groups. The EM group revealed enhanced rsFC of left SPG with left AG than the CM and HC groups. In multiple linear regression, after controlling for age, body mass index (BMI) and disease duration, the rsFC of left SPG with left MOG (β = 48.896, p = 0.021) was found to predict the total Dizziness Handicap Inventory (DHI) score with an explained variance of 25.1%. Moreover, the rsFC of left SPG with left MOG (β = 1.253, p = 0.003) and right SMG (β = -1.571, p = 0.049) were significant predictors of migraine frequency, accounting for a total explained variance of 73.8%.

Conclusion

The functional impairments due to migraine chronification are primarily concentrated in the multisensory integration-related brain regions. Additionally, the rsFC of SPG with MOG can predict the frequency of migraine and the degree of vestibular dysfunction. Therefore, these neuroimaging features could be potential mechanisms and therapeutic targets for developing vestibular dysfunction in migraine.

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.

Assessment of balance and functional capacity in fibromyalgia patients with and without migraine

ObjectiveTo evaluate the balance and functional capacity of fibromyalgia patients’ with and without migraine.MethodsObservational study with 60 women, between 20 and 60 years old (47±9 years), who were allocated into the following groups: 1. fibromyalgia and migraine (n=49); 2. only fibromyalgia (n=11). The following were used: Migraine Disability Assessment Test (MIDAS) to analyze the impact of migraine on quality of life; Revised Fibromyalgia Impact Questionnaire (FIQ-R) to assess the impact of fibromyalgia; six-minute walk test (6MWT)to assess functional capacity and Berg Balance Scale (BBE) for balance analysis.ResultsThere was no difference between groups 1 and 2 regarding functional capacity (TC6M: 308.7 m ±107.33 vs. 298.8 m ±153.54; p=0.55) and balance (BBE: 48± 14 vs. 47±16; p=0.68) as well as the impact on quality of life (FIQ: 78.8±14.77 vs. 74.4±13.99; p=0.28 and MIDAS: 31 ±24).ConclusionsOur study showed that there was no difference in functional capacity, balance and quality of life in fibromyalgia patients compared to patients with fibromyalgia associated with migraine.

Migraine and balance impairment: Influence of subdiagnosis, otoneurological function, falls, and psychosocial factors

OBJECTIVE

To assess the balance sensory organization among patients with migraine, considering the influence of migraine subdiagnosis, otoneurological function, falls, and psychosocial factors.

BACKGROUND

Migraine has been associated with vestibular symptoms and balance dysfunction; however, neither comprehensive balance assessment nor associated factors for greater impairment have been addressed thus far.

METHODS

Patients from a tertiary headache clinic with a diagnosis of episodic migraine with aura (MWA), without aura (MWoA), and chronic migraine (CM) were included for this cross-sectional study (30 patients per group). Thirty headache-free controls (CG) were recruited. Participants underwent a comprehensive evaluation protocol, including the Sensory Organization Test (SOT) and otoneurological examination. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered.

RESULTS

All migraine groups presented lower composite SOT scores than controls (CG: 82.4 [95% confidence interval (CI): 79.5-85.3], MWoA: 76.5 [95% CI: 73.6-79.3], MWA: 66.5 [95% CI: 63.6-69.3], CM: 69.1 [95% CI: 66.3-72.0]; p < 0.0001). Compared to controls and to MWoA, MWA and CM groups exhibited greater vestibular (CG: 75.9 [95% CI: 71.3-80.4], MWoA: 67.3 [95% CI: 62.7-71.8], MWA: 55.7 [95% CI: 51.2-60.3], CM: 58.4 [95% CI: 53.8-63.0]; p < 0.0001) and visual functional impairment (CG: 89.6 [95% CI: 84.2-94.9], MWoA: 83.2 [95% CI: 77.9-88.6], MWA: 68.6 [95% CI: 63.3-74.0], CM: 71.9 [95% CI: 66.5-77.2], p < 0.0001). Fall events during the assessment were documented more often among patients with migraine (CG: 0.0, interquartile range [IQR], 0.0, 0.0); MWoA: 1.0 [IQR: 1.0, 1.0], MWA: 2.0 [IQR: 1.8, 4.3], CM: 1.0 [IQR: 1.0, 2.0]; p = 0.001). The SOT scores correlated with fear of falls (r = -0.44), dizziness disability (r = -0.37), kinesiophobia (r = -0.38), and migraine frequency (r = -0.38). There was no significant influence of the vestibular migraine diagnosis in the study outcomes when used as a covariate in the analysis (composite score [F = 3.33, p = 0.070], visual score [F = 2.11, p = 0.149], vestibular score [F = 1.88, p = 0.172], somatosensory score [F = 0.00, p = 0.993]).

CONCLUSIONS

Aura and greater migraine frequency were related to falls and balance impairment with sensory input manipulation, although no otoneurological alterations were detected. The diagnosis of vestibular migraine does not influence the balance performance. The vestibular/visual systems should be considered in the clinical examination and treatment of patients with migraine.

Gait control of migraine patients with increasing light and sound levels

BACKGROUND

Under a typical light and sound environment context, individuals with migraine showed balance control deficits on a series of functional activities, which helps to explain why migraineurs report more falls. it isn't established, the effects of intensity light and sound in migraineurs during functional tasks.

RESEARCH QUESTION

Based on the hypersensitivity to light and sound in migraineurs, not only during the attack but also in the interictal period, does the exposure to bright light and loud sound impact motor control in this population?

METHODS

This cross-sectional study consisted of 51 women with migraine and 22 healthy women. They performed three walking tasks: crossing an obstacle, stepping-up and stepping-down a curb, in a control situation with ambient lighting (≅350 lux), bright light (≅1200 lux), and loud sound (≅90 dBa). For statistical analysis, a t-test, a Spearman correlation test, and a repeated measures mixed ANOVA were applied.

RESULTS

Migraineurs presented higher discomfort induced by light (p ≤ 0.0001) and sound (p = 0.001). In the obstacle task, migraineurs had greater step width than controls in the ambient light condition (p = 0.038) and participants of both groups placed their leading foot farther away from the obstacle in the light (p = 0.033) than in the ambient light condition. For the step-up task, this distance increased for both groups and limbs in the light (leading limb: p = 0.015; trailing limb: p = 0.002) and sound (leading limb: p = 0.010; trailing limb: p ≤ 0.0001) conditions compared to the ambient light condition. Step speed increased for light and sound conditions compared to ambient light condition, except for the sound condition in the step-down task.

SIGNIFICANCE

Despite the higher discomfort induced by light and sound in the migraineurs, the effects of these sensory manipulations were similar for both migraineurs and controls, except for step width. Light and sound manipulation induced a less conservative strategy to deal with uneven terrain in both groups.

Migraine With Aura Is Related to Delayed Motor Control Reaction and Imbalance Following External Perturbations

Background: It is evidenced that migraineurs present balance deficits. However, the balance recovery following unexpected ground perturbations, which reflect conditions of everyday activities, has not been investigated in this population. Aim: We aimed to assess the reactive postural responses among patients with migraine with and without aura, chronic migraine, and controls. We further aimed to assess the factors associated with greater self-report of falls. Methods: Ninety patients diagnosed by headache specialists were equally classified into three migraine subgroups according to the presence of aura and chronic migraine. Thirty controls were also recruited. All participants underwent the motor control test (MCT) and adaptation test (ADT) protocols of dynamic posturography tests (EquiTest®, NeuroCom, USA). Clinical and headache features and information on falls in the previous year, fear of falling, and vestibular symptoms were also assessed. Results: Patients with aura presented a greater sway area in most of the MCT conditions than the other three groups (p = 0.001). The aura group also presented delayed latency responses after perturbations compared with controls and patients without aura (p < 0.03). In the ADT, a greater sway area was observed in patients with aura than in groups without aura, chronic migraine, and controls (p < 0.0001). The MCT and ADT sway area, the frequency of aura, and the fear of falling explained 46% of the falls in the previous 12 months. Conclusion: Patients with aura exhibited greater delay and sway area after unexpected ground perturbations than controls and other migraine subgroups, which are related to the reported number of falls.

Is kinesiophobia related to fear of falling, dizziness disability, and migraine disability in patients with migraine?

INTRODUCTION

Kinesiophobia is a common symptom associated with high disability, and has been observed in patients with migraine. However, the association between kinesiophobia and clinical factors in this population is unknown.

OBJECTIVE

To assess the fear of falling, dizziness disability, and migraine disability in patients with migraine, considering the presence of kinesiophobia.

METHODS

Eighty patients with migraine completed the Tampa Scale for Kinesiophobia and were divided into two groups according to the questionnaire cutoff point: migraine without kinesiophobia (MoK, n = 39) and migraine with kinesiophobia (MK, n = 41). Fear of falling, dizziness disability, and migraine disability were assessed in both groups using validated questionnaires.

RESULTS

The MK group presented higher scores on dizziness disability, fear of falling, and migraine disability compared to the MoK (p < .05). Kinesiophobia can explain 29% of the variance in dizziness disability and 18% of migraine disability. Both kinesiophobia and the presence of dizziness can explain 14% of fear of falling variability. Also, kinesiophobia is associated with the risk of presenting fear of falling (Prevalence Ratio = 2.4, p = .012), and migraine disability (Prevalence Ratio = 2.6, p = .01).

CONCLUSION

The presence of kinesiophobia should be considered in clinical practice when evaluating migraine, as it is associated with increased levels of fear of falling, dizziness disability, and migraine disability.

Differentiating migraine, cervicogenic headache and asymptomatic individuals based on physical examination findings: a systematic review and meta-analysis

BACKGROUND

Migraine and cervicogenic headache (CGH) are common headache disorders, although the large overlap of symptoms between them makes differential diagnosis challenging. To strengthen differential diagnosis, physical testing has been used to examine for the presence of musculoskeletal impairments in both conditions. This review aimed to systematically evaluate differences in physical examination findings between people with migraine, CGH and asymptomatic individuals.

METHODS

The databases MEDLINE, PubMed, CINAHL, Web of Science, Scopus, EMBASE were searched from inception until January 2020. Risk of bias was assessed with the Downs and Black Scale for non-randomized controlled trials, and with the Quality Assessment of Diagnostic Accuracy Studies tool for diagnostic accuracy studies. When possible, meta-analyses with random effect models was performed.

RESULTS

From 19,682 articles, 62 studies were included in this review and 41 were included in the meta-analyses. The results revealed: a) decreased range of motion [°] (ROM) on the flexion-rotation test (FRT) (17.67, 95%CI:13.69,21.65) and reduced neck flexion strength [N] (23.81, 95%CI:8.78,38.85) in CGH compared to migraine; b) compared to controls, migraineurs exhibit reduced flexion ROM [°] (- 2.85, 95%CI:-5.12,-0.58), lateral flexion ROM [°] (- 2.17, 95% CI:-3.75,-0.59) and FRT [°] (- 8.96, 95%CI:-13.22,-4.69), reduced cervical lordosis angle [°] (- 0.89, 95%CI:-1.72,-0.07), reduced pressure pain thresholds over the cranio-cervical region [kg/cm²], reduced neck extension strength [N] (- 11.13, 95%CI:-16.66,-5.6) and increased activity [%] of the trapezius (6.18, 95%CI:2.65,9.71) and anterior scalene muscles (2.87, 95%CI:0.81,4.94) during performance of the cranio-cervical flexion test; c) compared to controls, CGH patients exhibit decreased neck flexion (- 33.70, 95%CI:-47.23,-20.16) and extension (- 55.78, 95%CI:-77.56,-34.00) strength [N].

CONCLUSION

The FRT and neck flexion strength could support the differential diagnosis of CGH from migraine. Several physical tests were found to differentiate both headache types from asymptomatic individuals. Nevertheless, additional high-quality studies are required to corroborate these findings.

STUDY REGISTRATION

Following indications of Prisma-P guidelines, this protocol was registered in PROSPERO on 21/05/2019 with the number CRD42019135269 . All amendments performed during the review were registered in PROSPERO, indicating the date and what and why was changed.

Comparison of static and dynamic balance measurements among chronic and episodic migraine patients

BACKGROUND

Migraine is one of the most frequent and incapacitating headaches, with a high degree of impairment of balance control and postural stability.

OBJECTIVE

To investigate the effects of episodic and chronic migraine on postural balance through using static and dynamic balance tests.

METHODS

The study included 32 chronic and 36 episodic migraine patients and a control group of 36 healthy volunteers. Right/left single-leg static and dynamic balance tests were performed in each group with eyes open and closed using a posturographic balance platform (Techno-body Prokin).

RESULTS

No significant difference was found among episodic and chronic migraine patients and control subjects with regard to eyes-open and eyes-closed area values (eyes-open area values: p=0.559, p=0.414 and p=0.906; eyes-closed area values: p=0.740, p=0.241 and p=0.093, respectively). However, the area values were significantly higher in episodic and chronic migraine patients than in the control group, which indicates that migraine patients may have lower balance performance. Perimeter values were relatively higher which supports the idea that migraine patients have lower balance performance. Additionally, the average number of laps was significantly lower among migraine patients than in the control group, which also implies that migraine patients may have lower balance performance.

CONCLUSION

Although no significant difference was detected between chronic and episodic migraine patients and the control group and between chronic and episodic migraine patients with regard to balance performance, chronic migraine patients seemed to have relatively lower performance than episodic migraine patients. Further studies with larger numbers of patients are needed, to investigate the relationship between these parameters and balance.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study

Background

Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs.

Methods

The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model.

Results

The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant.

Conclusions

The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.

Physical therapy and migraine: musculoskeletal and balance dysfunctions and their relevance for clinical practice

BACKGROUND

Migraine is a primary headache with high levels of associated disability that can be related to a variety of symptoms and comorbidities. The role of physical therapy in the management of migraine is largely unknown. Therefore, the aim of this review is to highlight and critically discuss the current literature and evidence for physical therapy interventions in individuals with migraines.

METHODS

A narrative review of the literature was performed.

RESULTS

Physical therapists assessing and treating patients with migraine should focus on two primary aspects: (1) musculoskeletal dysfunctions, and (2) vestibular symptoms/postural control impairment. Signs and symptoms of musculoskeletal and/or vestibular dysfunctions are prevalent among individuals with migraines and different disability levels can be observed depending on the presence of aura or increment of the migraine attacks.

CONCLUSION

A proper physical examination and interview of the patients will lead to a tailored treatment plan. The primary aim regarding musculoskeletal dysfunctions is to reduce pain and sensitization, and physical therapy interventions may include a combination of manual therapy, exercise therapy, and education. The aim regarding postural control impairment is to optimize function and reduce vestibular symptoms, and interventions should include balance exercises and vestibular rehabilitation. However, consistent evidence of benefits is still lacking due to the lack of and therefore need for tailored and pragmatic clinical trials with high methodological quality.

Presence of vestibular symptoms and related disability in migraine with and without aura and chronic migraine

Objective

To assess the presence and handicap due to vestibular symptoms in three subgroups of patients with migraine and controls.

Methods

Women between 18–55 years old were diagnosed by headache specialists and stratified as migraine with aura (n = 60), migraine without aura (n = 60), chronic migraine (n = 60) and controls (n = 60). Information regarding demographics, headache and vestibular symptoms were collected in this cross-sectional study. The self-perceived handicap related to vestibular symptoms was assessed through the Dizziness Handicap Inventory questionnaire.

Results

A total of 85% of women with migraine with aura and chronic migraine had vestibular symptoms contrasted to 70% of the migraine without aura group ( p < 0.05), and 12% of the control group reported symptoms ( p < 0.0001). Patients with migraine exhibited greater Dizziness Handicap Inventory scores than controls ( p < 0.001); and migraine with aura and chronic migraine groups reached greater scores than migraine without aura ( p < 0.01). Presence of migraine is associated with a greater risk of vestibular symptoms (migraine without aura: 5.20, migraine with aura: 6.60, chronic migraine:6.20, p < 0.0003) and with a greater risk of moderate-to-severe handicap (migraine without aura: 20.0, migraine with aura: 40.0, chronic migraine: 40.0, p < 0.0003). The presence of aura and greater migraine frequency adds to the risk of any handicap (migraine with aura: 1.9, chronic migraine: 1.7, p < 0.04) and to the risk of moderate-to-severe handicap (migraine with aura: 2.0, chronic migraine: 2.0, p < 0.0003). Migraine aura, intensity and frequency predict 36% of the dizziness handicap.

Conclusion

The prevalence of vestibular symptoms is increased in migraine during and between headache attacks, particularly in migraine with aura and chronic migraine along with an increased handicap due to those symptoms. Vestibular symptoms among subgroups of migraine should be considered when evaluating the functional impact of migraine.

Assessment of the Postural Stability of Female and Male Athletes

OBJECTIVE

Postural stability is often affected by sport-related injuries and subsequently evaluated during postinjury examinations. Intrinsic factors, however, may also affect postural control. We sought to compare the postural control of female and male athletes as measured simultaneously by (1) the modified balance error scoring system (mBESS) and (2) a video-force plate system.

DESIGN

Cross-sectional study.

SETTING

Sports injury prevention center.

PARTICIPANTS

Pediatric, adolescent, and young adult athletes who performed mBESS during an injury prevention evaluation.

INDEPENDENT VARIABLES

We compared the postural control of female and male athletes. We also accounted for independent variables associated with postural stability, including age, body mass index, and history of ankle injury, concussion, and migraine headache.

MAIN OUTCOME MEASURES

Total errors committed during the mBESS and measurements derived from integrated kinematic and kinetic data obtained by a video-force plate system. Differences between males and females were tested using analysis of covariance.

RESULTS

Participants (n = 409) ranged in age from 10 to 29 years (mean = 14.6 ± 2.8); 60% were female. No significant differences on mBESS were detected between females and males; however, female athletes demonstrated significantly better postural stability on the video-force plate analysis during double-leg (P = 0.03, d = 0.28), single-leg (P < 0.001, d = 0.62), and tandem stances (P < 0.001, d = 0.53) when compared with males.

CONCLUSIONS

Uninjured female athletes demonstrate better postural stability on video-force plate analysis than their uninjured male counterparts. These findings provide an important information assistive to clinicians during interpretation of postinjury balance tests.

Evaluation of postural stability in youth athletes: the relationship between two rating systems

OBJECTIVES

The Balance Error Scoring System (BESS) has been documented as a useful way to evaluate postural control following sport-related concussions sustained by youth athletes. However, limitations have been reported with its use due to the reliance on visual observation as the primary measurement outcome. The primary purpose of this study was to examine the correlation between the modified BESS (mBESS) as rated by a clinician and a simultaneous analysis performed by an integrated video-force plate system. The secondary purpose was to assess if a history of prior concussion affected postural control.

METHODS

A group of healthy youth athletes (n = 398; mean age 13.7 ± 2.4 years) completed the mBESS while simultaneously undergoing an integrated video-force plate evaluation to measure postural stability. Spearman rank-order correlations were used to determine the strength of correlation between the 2 rating systems. In addition, performance on the mBESS between those with and without a history of concussion was compared using univariate ANCOVAs.

RESULTS

A moderately high correlation was found during single-leg stance (ρ = -0.64, p < .001), while a weak correlation was found during tandem stance (ρ = -0.30, p < .001). No postural control differences were found between groups with and without a concussion history.

CONCLUSION

The video-force plate rating system correlates well with the clinician rating during the single-leg stance of the mBESS, but not during double-leg or tandem stances. A history of concussion did not affect mBESS scores.

Single-leg postural stability deficits following anterior cruciate ligament reconstruction in pediatric and adolescent athletes

The objective of this study was to compare the postural stability of pediatric and adolescent athletes without anterior cruciate ligament injury with those who underwent anterior cruciate reconstruction (ACLR). Postural stability ratings derived from a video-force plate system during the three stances of the modified Balance Error Scoring System were collected from pediatric and adolescent athletes who underwent ACLR (N=24; mean 1.2 years after surgery) and from uninjured controls (N=479). The postural control rating was calculated as the mean of the displacement and variance of the torso and center of pressure data, normalized on a scale from 0 to 100. A higher rating indicates greater postural stability. Participants who underwent ACLR showed lower postural stability ratings during single-leg stance compared with uninjured controls (40.0 vs. 48.7; P=0.037). ACLR is associated with deficits in postural stability.

Additional Effects of a Physical Therapy Protocol on Headache Frequency, Pressure Pain Threshold, and Improvement Perception in Patients With Migraine and Associated Neck Pain: A Randomized Controlled Trial

OBJECTIVE

To evaluate the additional effect provided by physical therapy in migraine treatment.

DESIGN

Randomized controlled trial.

SETTING

Tertiary university-based hospital.

PARTICIPANTS

Among the 300 patients approached, 50 women (age range, 18-55y) diagnosed with migraine were randomized into 2 groups: a control group (n=25) and a physiotherapy plus medication group (n=25) (N=50).

INTERVENTIONS

Both groups received medication for migraine treatment. Additionally, physiotherapy plus medication patients received 8 sessions of physical therapy over 4 weeks, comprised mainly of manual therapy and stretching maneuvers lasting 50 minutes.

MAIN OUTCOME MEASURES

A blinded examiner assessed the clinical outcomes of headache frequency, intensity, and self-perception of global change and physical outcomes of pressure pain threshold and cervical range of motion. Data were recorded at baseline, posttreatment, and 1-month follow-up.

RESULTS

Twenty-three patients experienced side effects from the medication. Both groups reported a significantly reduced frequency of headaches; however, no differences were observed between groups (physiotherapy plus medication patients showed an additional 18% improvement at posttreatment and 12% improvement at follow-up compared with control patients, P>.05). The reduction observed in the physiotherapy plus medication patients was clinically relevant at posttreatment, whereas clinical relevance for control patients was demonstrated only at follow-up. For pain intensity, physiotherapy plus medication patients showed statistical evidence and clinical relevance with reduction posttreatment (P<.05). In addition, they showed better self-perception of global change than control patients (P<.05). The cervical muscle pressure pain threshold increased significantly in the physiotherapy plus medication patients and decreased in the control patients, but statistical differences between groups were observed only in the temporal area (P<.05). No differences were observed between groups regarding cervical range of motion.

CONCLUSIONS

We cannot assume that physical therapy promotes additional improvement in migraine treatment; however, it can increase the cervical pressure pain threshold, anticipate clinically relevant changes, and enhance patient satisfaction.

Migraine and dizziness

PURPOSE OF REVIEW

Awareness of the importance of migraine in patients with symptoms of vestibular dysfunction is increasing. This article gives an overview of the multiple facets of the link between migraine and vestibular dysfunction.

RECENT FINDINGS

The vestibular and the headache community have published a consensual definition of vestibular migraine, which is an important step to promote research on the topic and the awareness of clinicians. Vestibular migraine is considered the most common cause of spontaneous recurrent vertigo. So far, the evidence for vestibular migraine has been mainly epidemiological, but the recent follow-up of a cohort over 9 years could show the robustness of the diagnosis over time.Additionally, migraine and vestibular dysfunction have multiple potential interactions and links through a range of comorbidities such as Menière's disease, benign paroxysmal positional vertigo, anxiety and motion sickness, which go beyond the diagnostic entity of vestibular migraine.

SUMMARY

The further refinement and wider acceptance of the diagnostic entity of vestibular migraine is an important development as it is one the most common vestibular disorders. But the relationship between migraine and vestibular dysfunction is complex and has many aspects beyond vestibular migraine.