Migraine: an alternative in the diagnosis of unclassified vertigo

Vestibular migraine: An update on current understanding and future directions

BACKGROUND

Vestibular migraine is among the most common causes of recurrent vertigo in the general population. Despite its prevalence and high impact on healthcare cost and utilization, it has remained an under-recognized condition with largely unknown pathophysiology. In the present article, we aim to provide an overview of the current understanding of vestibular migraine.

METHODS

We undertook a narrative literature review on the epidemiology, presentations, clinical and laboratory findings, pathophysiology, and treatments of vestibular migraine.

RESULTS

Currently, the diagnosis of vestibular migraine relies solely on clinical symptoms since clinical tests of vestibular function are typically normal, or difficult to interpret based on inconsistent results reported in earlier studies. The challenges related to diagnosis of vestibular migraine lie in its relatively broad spectrum of manifestations, the absence of typical migraine headaches with vestibular symptoms, and its very recent definition as a distinct entity. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in vestibular migraine, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the pathophysiology and treatment of vestibular migraine are also discussed.

CONCLUSION

Vestibular migraine is still underdiagnosed clinically. Future studies are needed to address the pathophysiological mechanisms and investigate effective treatment regimens.

Migraine and benign paroxysmal positional vertigo: a single-institution review

Background:

Benign paroxysmal positional vertigo and migraine-associated dizziness are common. The prevalence of benign paroxysmal positional vertigo seems to be higher in patients with migraine-associated dizziness than in those without migraine.

Methods:

A database of 508 patients seen at the primary author's balance clinic was analysed to determine the prevalence of migraine, as defined by International Headache Society criteria, in patients with benign paroxysmal positional vertigo.

Results:

The percentage of patients with dizziness or vertigo who met criteria for migraine was 33.7 per cent, with a prevalence of benign paroxysmal positional vertigo of 42.3 per cent. When excluding patients with migrainous vertigo, patients with migraine frequently had benign paroxysmal positional vertigo (66.7 per centvs55.8 per cent), although this finding was not statistically significant.

Conclusion:

The results for the entire sample suggest that, after excluding patients with migrainous vertigo, patients with migraine seem more likely to have benign paroxysmal positional vertigo; however, this association was not significant, probably because of the small sample size.

Vestibular migraine

During the last decades a new vestibular syndrome has emerged that is now termed vestibular migraine (VM). The main body of evidence for VM is provided by epidemiologic data demonstrating a strong association between migraine and vestibular symptoms. Today, VM is recognized as one of the most common causes of episodic vertigo. The clinical presentation of VM is heterogeneous in terms of vestibular symptoms, duration of episodes, and association with migrainous accompaniments. Similar to migraine, there is no clinical or laboratory confirmation for VM and the diagnosis relies on the history and the exclusion of other disorders. Recently, diagnostic criteria for VM have been elaborated jointly by the International Headache Society and the Bárány Society. Clinical examination of patients with acute VM has clarified that the vast majority of patients with VM suffer from central vestibular dysfunction. Findings in the interval may yield mild signs of damage to both the central vestibular and ocular motor system and to the inner ear. These interictal clinical signs are not specific to VM but can be also observed in migraineurs without a history of vestibular symptoms. How migraine affects the vestibular system is still a matter of speculation. In the absence of high-quality therapeutic trials, treatment is targeted at the underlying migraine.

Vestibular migraine

Vestibular migraine is now considered a distinct diagnostic entity by both the Barany Society and the International Headache Society. The recognition of vestibular migraine as a diagnostic entity required decades and was presaged by several reports indicating that a large proportion of patients with migraine headaches have vestibular symptoms and that a large proportion of patients with undiagnosed episodic vestibular symptoms have migraine headache. Despite the availability of diagnostic criteria for vestibular migraine, challenges to diagnosis include variability in terms of the character of dizziness, the presence or absence of clearly defined attacks, the duration of attacks, and the temporal association between headache or other migrainous features and vestibular symptoms. Also, symptoms of vestibular migraine often overlap with symptoms of other causes of dizziness, especially Ménière's disease and benign paroxysmal positional vertigo (BPPV). This article will discuss the demographics, epidemiology, clinical manifestations, physical examination findings, laboratory testing, comorbidities, treatment options, and pathophysiology of vestibular migraine. Future research in the field of vestibular migraine should include both clinical and basic science efforts to better understand the pathophysiology of this condition. Controlled treatment trials for vestibular migraine are desperately needed.

Migraine-associated vertigo: diagnosis and treatment

Migraine-associated vertigo has become a well-recognized disease entity diagnosed based on a clinical history of recurrent vertigo attacks unexplained by other central or peripheral otologic abnormalities, which occurs in the patient with a history of migraine headaches. There is no international agreement on what spectrum of symptoms should be covered under this diagnosis, or what terminology should be used. The headaches and vestibular symptoms of migraine-associated vertigo may not be temporally associated, which often obscures the association. Diagnostic tests usually show nonspecific abnormalities that are also seen in patients with migraine who do not experience vestibular symptoms. Management generally follows the recommended treatment of migraine headaches, and includes dietary and lifestyle modifications and medical treatment with beta blockers, calcium channel blockers, and tricyclic amines. Small case series show that acetazolamide and lamotrigine appear to be more effective for the vertigo attacks than headaches. Vestibular rehabilitation has also been shown to be helpful in several studies. In this review, the epidemiologic and clinical features of the disorder, as well as the current state of knowledge on pathophysiology, diagnostic testing, and treatment are described.

Vestibular migraine

Vestibular migraine is a chameleon among the episodic vertigo syndromes because considerable variation characterizes its clinical manifestation. The attacks may last from seconds to days. About one-third of patients presents with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms. During attacks most patients show spontaneous or positional nystagmus and in the attack-free interval minor ocular motor and vestibular deficits. Women are significantly more often affected than men. Symptoms may begin at any time in life, with the highest prevalence in young adults and between the ages of 60 and 70. Over the last 10 years vestibular migraine has evolved into a medical entity in dizziness units. It is the most common cause of spontaneous recurrent episodic vertigo and accounts for approximately 10% of patients with vertigo and dizziness. Its broad spectrum poses a diagnostic problem of how to rule out Menière's disease or vestibular paroxysmia. Vestibular migraine should be included in the International Headache Classification of Headache Disorders (ICHD) as a subcategory of migraine. It should, however, be kept separate and distinct from basilar-type migraine and benign paroxysmal vertigo of childhood. We prefer the term "vestibular migraine" to "migrainous vertigo," because the latter may also refer to various vestibular and non-vestibular symptoms. Antimigrainous medication to treat the single attack and to prevent recurring attacks appears to be effective, but the published evidence is weak. A randomized, double-blind, placebo-controlled study is required to evaluate medical treatment of this condition.

Epidemiology of vertigo, migraine and vestibular migraine

Both migraine and vertigo are common in the general population with lifetime prevalences of about 16 % for migraine and 7 % for vertigo. Therefore, a concurrence of the two conditions can be expected in about 1.1 % of the general population by chance alone. However, recent epidemiological evidence suggests that the actual comorbidity is higher, namely 3.2 %. This can be explained by the fact that several dizziness and vertigo syndromes occur more frequently in migraineurs than in controls including benign paroxysmal positional vertigo, Meniere's disease, motion sickness, cerebellar disorders and anxiety syndromes which may present with dizziness. In addition, there is increasing recognition of a syndrome called vestibular migraine (VM), which is vertigo directly caused by migraine. VM affects more than 1 % of the general population, about 10 % of patients in dizziness clinics and at least 9 % of patients in migraine clinics.Clinically, VM presents with attacks of spontaneous or positional vertigo lasting seconds to days. Migrainous accompaniments such as headache, phonophobia, photophobia or auras are common but not mandatory. Cochlear symptoms may be associated but are mostly mild and non-progressive. During acute attacks one may find central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval, vestibular testing adds little to the diagnosis as findings are mostly minor and non-specific. In the absence of controlled studies, treatment of VM is adopted from the migraine sphere comprising avoidance of triggers, stress management as well as pharmacotherapy for acute attacks and prophylaxis.

Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine

OBJECTIVE

The aim of this study was to determine the lifetime prevalence of vertigo and dizziness in patients with migraine as compared with controls and to establish the lifetime prevalence of migrainous vertigo.

BACKGROUND

Dizziness and vertigo are relatively frequent complaints in general population; however, the prevalence of migrainous vertigo has not been extensively studied so far.

METHODS

The study included 327 migraine patients and 324 controls who do not suffer from frequent headaches. The study and control group were assessed clinically and through diagnostic workup for having vertigo, dizziness, hypotension, and sideropenic anemia.

RESULTS

Vertigo or dizziness was experienced by 51.7% of migraine patients (MVL group) and 31.5% in the control group (CVL group), P < .0001. Among the MVL group, 23.2% of patients met the criteria for migrainous vertigo. There was no difference between the MVL group and CVL group in frequency of attacks or the pattern of symptom appearance in relation to head movement. Patients in the MVL group more frequently had hypotension, P = .011. Patients with migraine with aura significantly more often had migraine attacks in association with vertigo or dizziness, P < .0001.

CONCLUSION

The lifetime prevalence of migrainous vertigo is relatively frequent in migraine patients, especially in migraine with aura.

Phenotypic and genetic analysis of a large family with migraine-associated vertigo

OBJECTIVES

To describe a large multigenerational family with migraine-associated vertigo (MAV) combining a detailed phenotypic and genetic analysis.

BACKGROUND

Migraine-associated vertigo is said to be highly prevalent in the general population and, like other migraine syndromes, its etiology is felt to have a strong genetic component. However, so far, there have been no reports of large families with MAV.

METHODS

Detailed clinical study was conducted on a large multigenerational family with MAV. Genetic study using identical-by-descent analysis with dense single nucleotide polymorphism (SNP) arrays was performed to examine consistent inheritance pattern among the affecteds.

RESULTS

Clinical features of MAV were variable although most had other migraine symptoms with at least some of their attacks. We did not find a region of the genome shared by all eight subjects with MAV indicating a polygenetic inheritance for MAV even in this single large family.

CONCLUSIONS

A region on 11q shared by most affected females may contain a susceptibility allele for MAV that is expressed exclusively or predominantly by women.

Association of progesterone receptor with migraine-associated vertigo

While migraine has been demonstrated to be familial and have genetic contributions, genome-wide linkage analyses and candidate gene studies have highlighted that migraine is genetically complex. Despite substantial efforts, no consistent replication of linkage or association has been reported for common migraine syndromes. Among the candidate genes tested for association with migraine by several groups were female sex hormone genes based on the observation of a much higher incidence of migraine in females. Migraine-associated vertigo (MAV) is a migraine syndrome also much more common in females than males. Because MAV is less common in the general population than migraine or migraine with aura, it may be a better migraine syndrome to detect susceptibility alleles. In this study, we tested the association of two female hormonal genes, progesterone receptor (PGR) and estrogen receptor (ESR1), which were previously reported to be associated with migraine in women. We typed 150 MAV subjects and 145 genomic matched control subjects. One SNP (rs1042838) within PGR, which is in high linkage disequilibrium with the functional PROGINS variant, was significantly associated with MAV (p = 0.0007). Two SNPs (rs2228480 and rs1801132) within ESR1 demonstrated no significant association. No synergistic effect between ESR1 variants and PGR variants was identified.

Migraine-related vertigo: diagnostic criteria and prophylactic treatment

OBJECTIVE/HYPOTHESIS

The objective of this prospective, observational study was to evaluate the efficacy of migraine pharmacologic prophylaxis on a group of vertiginous patients considered affected by migraine-related vertigo on the basis of precise criteria of inclusion.

METHODS

Fifty-three patients affected by migraine-related vertigo were selected from a cohort of 652 vertiginous patients referred to our Dizziness Unit from March 2001 to June 2005. Inclusion criteria were at least five vertigo attacks occurred in any period of time or dizziness and/or positional vertigo for at least 6 months; migraine, past or present, and/or a family history of migraine and/or motion intolerance; and exclusion of other causes. Patients were submitted to migraine pharmacologic prophylaxis selected on the basis of the characteristics of the patients and of the drug side effects. The efficacy of the treatment was evaluated after 6 months by questionnaire divided into five outcome categories (resolution, substantial control, moderate control, minimal control, no improvement or worsening) and, for the patients with recurrent vertiginous attacks, also reporting the percentage reduction of the attack frequency.

RESULTS

Thirty-six patients completed the study and were submitted to analysis of the results: 10 reported complete resolution of symptoms, 15 substantial control, 7 moderate control, one minimum control and 3 no improvement. Thirty-three of them had recurrent vertigo: 19 reported complete disappearance of the attacks, 8 reduction of the frequency >50%, 5 reduction <50%, and one no reduction.

CONCLUSIONS

Migraine prophylactic treatment shows encouraging results in patients with migraine-related vertigo selected with our criteria of inclusion: 69.3% reported satisfactory control of symptoms (sum of complete resolutions and substantial controls) and 81.8% had at least a 50% reduction of the vertiginous episodes frequency.

Trigeminal stimulation elicits a peripheral vestibular imbalance in migraine patients

OBJECTIVE

The study explored the hypothesis that spontaneous nystagmus (Ny) in migraine patients can be triggered or modulated by painful trigeminal stimulation, providing evidence of a functional connection between vestibular and trigeminal systems.

BACKGROUND

Vertigo attacks are reported by subjects with migraine or a familiar history of migraine, also independently of headache episodes. Idiopathic vertigo is three times more frequent in migraine patients than in controls. Vestibular investigations in migraine patients have consistently demonstrated spontaneous Ny both of central and peripheral origin.

DESIGN

In the first phase of the study 10 outpatients experiencing migraine without aura (MO) and 10 healthy volunteers were submitted to the registration of spontaneous primary-position Ny in the dark by Ulmer's video-ocular-nystagmographic equipment. Two electrodes for electrical stimulation were applied on the supraorbital point of one side of the head and the intensity of stimulation corresponding to pain threshold was calculated. Spontaneous ocular movements were recorded for 5 minutes at baseline and after a sequence of five electric pulses (square waves of .5 Hz frequency and 50 micros duration, at pain threshold intensity). Nystagmographic responses were expressed as latency after stimulation, direction of the quick phase, and duration. The second phase of the study explored, with the same procedure, the effects on Ny of supraorbital versus median nerve stimulation in other 10 MO patients. Responses to stimulation were considered the appearance of de novo Ny after stimulation in subjects without baseline Ny, or the change of the frequency (at last a 50% variation) or of the direction of Ny after stimulation in subjects with baseline Ny. The latency and the duration of responses to stimulation were also calculated.

RESULTS

In the first series supraorbital painful electric stimulation was able to modify or to evoke Ny in 8 of 10 migraineurs and in none of 10 volunteers (Fisher's exact test, P<.01). Both the baseline and the induced Ny were second degree, stationary persistent, with a linear slow phase and were suppressed by visual fixation. In the second series, supraorbital nerve stimulation was able to induce or modify Ny in all of 10 patients but only in 1 patient Ny was induced by median nerve stimulation. Characters of Ny were the same as previously described. Statistical comparison of the responses at the two sites of stimulation was significant (Fisher's exact test, P<.01). In those 7 patients who presented de novo Ny after stimulation it was possible to calculate Ny latency and duration. The mean latency was 25 s (SD: 16, range: 14 to 60). The mean duration was 120 s (SD: 94, range: 20 to 290).

CONCLUSION

The main result of our study is that in migraine patients painful trigeminal stimulation elicits de novo, or modifies pre-existing spontaneous Ny, generally increasing it. The finding was obtained after trigeminal stimulation, but not after median nerve stimulation. We suggest that painful trigeminal stimulation can induce an imbalance of the vestibular system in migraine patients and possibly explain their predisposition to vertigo. Our data require confirmation by other studies.

Migraine-related vertigo: towards a distinctive entity

Both migraine and vertigo are common complaints. Although they may coincide by chance, there is growing evidence for a clinical entity of recurrent vestibular symptoms related to migraine. This syndrome implies a possible causal relationship although the pathophysiology of migraine-related vertigo has not been fully elucidated. A migrainous aseptic inflammation is thought to create a central sensitivity that spreads from the trigeminal to the vestibular system. Diagnostic criteria for migraine-related vertigo are proposed. Treatment is based on anti-vertiginous drugs for acute interventions and prophylactic measures as are taken for migraine headaches. Multicenter, prospective controlled studies are highly warranted.

Vertigo and dizziness related to migraine: a diagnostic challenge

Vertigo and dizziness can be related to migraine in various ways: causally, statistically or, quite frequently, just by chance. Migrainous vertigo (MV) is a vestibular syndrome caused by migraine and presents with attacks of spontaneous or positional vertigo lasting seconds to days and migrainous symptoms during the attack. MV is the most common cause of spontaneous recurrent vertigo and is presently not included in the International Headache Society classification of migraine. Benign paroxysmal positional vertigo (BPPV) and Ménière's disease (MD) are statistically related to migraine, but the possible pathogenetic links have not been established. Moreover, migraineurs suffer from motion sickness more often than controls. Persistent cerebellar symptoms may develop in the course of familial hemiplegic migraine. Dizziness may also be due to orthostatic hypotension, anxiety disorders or major depression which all have an increased prevalence in patients with migraine.

Vestibular rehabilitation outcomes in patients with a history of migraine

OBJECTIVES

The purpose of this study was to assess the efficacy of physical therapy for patients with vestibular disorders with and without a history of migraine headaches.

STUDY DESIGN

Retrospective case series.

SETTING

Outpatient physical therapy clinic.

PATIENTS

Thirty patients with both a history of migraine and a diagnosis of vestibular/balance disorder considered unrelated to migraine were identified by retrospective chart review. Thirty patients without a history of migraine, matched retrospectively by diagnosis, vestibular function, and age (+/-5 years), were used as a comparison group.

INTERVENTIONS

Both groups were treated with a custom-designed physical therapy program for a mean of 4.1 visits over a mean of 3.3 months.

MAIN OUTCOME MEASURES

Patients completed the Dizziness Handicap Inventory, the Activities-Specific Balance Confidence Scale, the Dynamic Gait Index, and the Timed Up & Go Test and rated the severity of their dizziness on an analog scale of 0 to 100.

RESULTS

Significant differences were demonstrated within both groups between initial evaluation and discharge in each of the assessment measures used. Patients with a history of migraine demonstrated worse scores on all outcome measures than did the patients without a history of migraine. There were no statistically significant differences between the two groups' scores before and after therapy except for the total Dizziness Handicap Inventory score at discharge (p < 0.05).

CONCLUSIONS

Patients with vestibular disorders with or without a history of migraine demonstrated improvements in both subjective and objective measures of balance after physical therapy. Patients with a history of migraine perceived a greater handicap from dizziness than did patients without a history of migraine that was greater than the difference in physical function performance measures between groups.

Migraine-associated dizziness: patient characteristics and management options

OBJECTIVE

To determine patient characteristics and effectiveness of therapy for migraine-associated dizziness.

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Patients were identified through a code query of billing records for the diagnosis of migraine-associated vertigo or disequilibrium, based on the International Headache Society criteria. There were 81 patients (61 women, 20 men) with an average age of 36.6 years (range, 8-71 yr); all except four patients were evaluated between 1995 and 1999. Follow-up was obtained from chart review. Mean follow-up time was 54.5 weeks, with a range of 4 to 456 weeks.

INTERVENTION

One or more treatment methods, including dietary manipulation, medication (tricyclic antidepressants, beta-blockers or calcium-channel blockers), and neurology consultation, were applied sequentially as necessary.

MAIN OUTCOME MEASURE

Response to therapy was defined as greater than 75% reduction in symptom recurrence rate.

RESULTS

Overall, 72% of patients experienced resolution or dramatic reduction of their attacks of vertigo or disequilibrium. Of the 13 patients treated with the introduction of dietary manipulation alone, 100% received significant relief. Of the 31 patients treated with dietary manipulation and the addition of a medication, 77% of these patients had significant relief. Of the final group of 37 patients treated with another medication or a neurology consultation, 57% received substantial relief. Of the responders, the majority (>95%) experienced an equal reduction in both vertigo or disequilibrium and headache symptoms. Interestingly, 100% of the patients in the migraine without active headache group received substantial relief of their vertigo or disequilibrium symptoms with migraine therapy.

CONCLUSION

We conclude that there is effective therapy for the common problem of migraine-associated dizziness.

Medical management of migraine-related dizziness and vertigo

Historically, review of migraine-related vestibular symptoms has focused on the various clinical presentations that occur and the results of diagnostic studies of vestibular function. Treatment of vestibular symptoms related to migraine has been proposed similar to that used for headache control, but few examples of the effectiveness of this therapy have been published. The purpose of this study is to present the various approaches that can be used to manage vestibular symptoms related to migraine, and to evaluate the overall effectiveness of these treatment approaches. This was a retrospective review of 89 patients diagnosed with migraine-related dizziness and vertigo. The character of vestibular symptoms, pattern of cochlear symptoms, results of auditory and vestibular tests, and comorbidity factors are presented. Treatment was individualized according to symptoms and comorbidity factors, and analyzed regarding effectiveness in control of the major vestibular symptoms of episodic vertigo, positional vertigo, and nonvertiginous dizziness. Medical management included dietary changes, medication, physical therapy, lifestyle adaptations, and acupuncture. Complete or substantial control of vestibular symptoms was achieved in 68 (92%) of 74 patients complaining of episodic vertigo; in 56 (89%) of 63 patients with positional vertigo; and 56 (86%) of 65 patients with non-vertiginous dizziness. Similarly, aural fullness was completely resolved or substantially improved in 34 (85%) of 40 patients; ear pain in 10 (63%) of 16 patients; and phonophobia in 17 (89%) of 19 patients. No patient reported worsened symptoms following medical management. The conflicting concept of a central disorder (migraine) as the cause of cochlear and vestibular dysfunction that often has peripheral features is discussed.

Migraine-associated vertigo

A retrospective analysis was performed on a consecutive series of 363 patients presenting with vertigo; 32% had migraine. Of the 224 patients with no pathology other than migraine or vestibular dysfunction, migraineurs had a significantly higher prevalence of normal, central, and combined central and peripheral vestibular dysfunction compared to non-migraineurs. The combination of central and peripheral vestibular signs was a feature of migraine with aura. The results support the hypothesis that migraine-associated vertigo is a diagnostic entity.

Database for Vertigo

An interactive database has been developed to assist the diagnostic procedure for vertigo and to store the data. The database offers a possibility to split and reunite the collected information when needed. It contains detailed information about a patient's history, symptoms, and findings in otoneurologic, audiologic, and imaging tests. The symptoms are classified info sets of questions on vertigo (including postural instability), hearing loss and tinnitus, and provoking factors. Confounding disorders are screened. The otoneurologic tests involve saccades, smooth pursuit, posturography, and a caloric test. In addition, findings from specific antibody tests, clinical neurotologic tests, magnetic resonance imaging, brain stem audiometry, and electrocochleography are included. The input information can be applied to workups for vertigo in an expert system called ONE. The database assists its user in that the input of information is easy. It not only can be used for diagnostic purposes but is also beneficial for research, and in combination with the expert system, it provides a tutorial guide for medical Students.

Paroxysmal vertigo as a migraine equivalent in children: a population-based study

We studied the prevalence, causes and clinical features of paroxysmal vertigo (PV) in the well-defined childhood population of the City of Aberdeen. We applied a screening questionnaire to 2165 children (10% random sample of all children 5-15 years of age) attending schools in Aberdeen. Children with a history of at least three episodes of vertigo over the past year due to unknown causes were invited for clinical interview and examination. Children with PV were compared with a group of children with migraine, and with a group of asymptomatic children matched for age and sex. Forty-five children fulfilled the diagnostic criteria for PV (prevalence rate 2.6%, 95% CI 1.9-3.4). They were noted to have clinical features in common with children with migraine, including trigger and relieving factors, associated gastrointestinal and sensory symptoms, vasomotor changes, and a similar pattern of associated recurrent disorders (such as headache, abdominal pain and cyclical vomiting), atopic diseases and travel sickness. Also, they had a twofold increase in the prevalence of migraine (24%) compared with the general childhood population (10.6%). The overlap in the clinical features of PV and migraine suggests that the two conditions are related and that it is reasonable to continue to regard PV as a migraine equivalent.