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Abstract
PURPOSE OF REVIEW To explore recent developments in vestibular migraine (VM). RECENT FINDINGS This review discusses the current diagnostic criteria for VM in the adult and pediatric populations, as proposed by the International Headache Society and Bárány Society. Recent VM studies confirm the prior findings and reveal new insights, including the wide range of vestibular symptoms, symptoms in the attack-free period, and triggers. Many patients experience persistent vestibular symptoms, even in the absence of acute attacks, which often significantly impact patients' quality of life. The syndrome of benign recurrent vertigo and its relationship to migraine, VM, and Meniere's disease is also discussed. There is a dearth of randomized controlled trials in VM treatment. Prospective and retrospective studies support the benefit of many migraine treatments are effective in VM, including neuromodulation, and calcitonin gene-related peptide monoclonal antibodies. VM affects almost 3% of the population, but remains under-diagnosed. Recent diagnostic criteria can help clinicians diagnose VM in adults and children.
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Affiliation(s)
- Shin C Beh
- Beh Center for Vestibular & Migraine Disorders, 4500 Hillcrest Rd Ste 145, Frisco, TX, 75035, USA.
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Mallampalli MP, Rizk HG, Kheradmand A, Beh SC, Abouzari M, Bassett AM, Buskirk J, Ceriani CEJ, Crowson MG, Djalilian H, Goebel JA, Kuhn JJ, Luebke AE, Mandalà M, Nowaczewska M, Spare N, Teggi R, Versino M, Yuan H, Zaleski-King A, Teixido M, Godley F. Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit. Front Neurol 2022; 12:812678. [PMID: 35046886 PMCID: PMC8762211 DOI: 10.3389/fneur.2021.812678] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Accepted: 11/29/2021] [Indexed: 12/03/2022] Open
Abstract
Vestibular migraine (VM) is an increasingly recognized pathology yet remains as an underdiagnosed cause of vestibular disorders. While current diagnostic criteria are codified in the 2012 Barany Society document and included in the third edition of the international classification of headache disorders, the pathophysiology of this disorder is still elusive. The Association for Migraine Disorders hosted a multidisciplinary, international expert workshop in October 2020 and identified seven current care gaps that the scientific community needs to resolve, including a better understanding of the range of symptoms and phenotypes of VM, the lack of a diagnostic marker, a better understanding of pathophysiologic mechanisms, as well as the lack of clear recommendations for interventions (nonpharmacologic and pharmacologic) and finally, the need for specific outcome measures that will guide clinicians as well as research into the efficacy of interventions. The expert group issued several recommendations to address those areas including establishing a global VM registry, creating an improved diagnostic algorithm using available vestibular tests as well as others that are in development, conducting appropriate trials of high quality to validate current clinically available treatment and fostering collaborative efforts to elucidate the pathophysiologic mechanisms underlying VM, specifically the role of the trigemino-vascular pathways.
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Affiliation(s)
- Monica P Mallampalli
- Department of Research, Association of Migraine Disorders, North Kingstown, RI, United States
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, SC, United States
| | - Amir Kheradmand
- Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Shin C Beh
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, United States
| | - Mehdi Abouzari
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, CA, United States
| | - Alaina M Bassett
- Department of Otolaryngology, Keck School of Medicine, University of Southern California, Los Angeles, CA, United States
| | - James Buskirk
- Department of Otolaryngology, University of Miami Miller School of Medicine, Miami, FL, United States
| | - Claire E J Ceriani
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Matthew G Crowson
- Department of Otolaryngology-Head and Neck Surgery, Mass Eye & Ear and Harvard Medical School, Boston, MA, United States
| | - Hamid Djalilian
- Department of Otolaryngology-Head and Neck Surgery, University of California, Irvine, Irvine, CA, United States
| | - Joel A Goebel
- Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, Saint Louis, MO, United States
| | - Jeffery J Kuhn
- Department of Research, Bayview Physicians Group, Chesapeake, VA, United States
| | - Anne E Luebke
- Biomedical Engineering and Neuroscience, University of Rochester Medical Center, Rochester, NY, United States
| | - Marco Mandalà
- Otolaryngology Unit, University of Siena, Siena, Italy
| | - Magdalena Nowaczewska
- Department of Otolaryngology, Head and Neck Surgery, Laryngological Oncology, Nicolaus Copernicus University, Torun, Poland
| | - Nicole Spare
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Roberto Teggi
- Department of Otolaryngology, San Raffaele Scientific Hospital, Milan, Italy
| | - Maurizio Versino
- Neurology and Stroke Unit, ASST Sette Laghi, Circolo Hospital, Varese, Italy
| | - Hsiangkuo Yuan
- Jefferson Headache Center, Thomas Jefferson University, Philadelphia, PA, United States
| | - Ashley Zaleski-King
- Department of Speech-Language Pathology & Audiology, Towson University, Towson, MD, United States
| | - Michael Teixido
- Department of Research, Association of Migraine Disorders, North Kingstown, RI, United States
| | - Frederick Godley
- Department of Research, Association of Migraine Disorders, North Kingstown, RI, United States
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Abstract
There is a reciprocal relationship between vestibular and neuropsychological disorders. People with vertigo and dizziness are at higher risk of various psychiatric disorders, particularly anxiety, depression, and panic disorder. On the other hand, people with mood disorders are at higher risk of experiencing vertigo and dizziness. Vestibular information plays a crucial role in cognitive processes, especially visuo-spatial abilities. Consequently, vestibular disorders (both peripheral and central) often result in visuo-spatial deficits. In addition, lesions of the cortical and subcortical components of the vestibular system result in disorders of higher vestibular function, such as hemispatial neglect, pusher syndrome, and topographagnosia.
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Affiliation(s)
- Shin C Beh
- Department of Neurology, Vestibular & Neuro-Visual Disorders Clinic, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Beh SC, Chiang HS, Sanderson C. In Reference to The Interconnections of Mal de Débarquement Syndrome and Vestibular Migraine. Laryngoscope 2021; 131:E2593. [PMID: 33625730 DOI: 10.1002/lary.29475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Hsueh-Sheng Chiang
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Collin Sanderson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Beh SC, Chiang HS, Sanderson C. The Interconnections of Mal de Débarquement Syndrome and Vestibular Migraine. Laryngoscope 2020; 131:E1653-E1661. [PMID: 33135784 DOI: 10.1002/lary.29214] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2020] [Revised: 10/03/2020] [Accepted: 10/15/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES/HYPOTHESIS Mal de débarquement syndrome (MDDS) is characterized by a persistent rocking sensation, as though on a boat. It may occur following exposure to passive motion (motion-triggered MDDS [MT-MDDS]), or spontaneously (spontaneous-onset MDDS [SO-MDDS]). This study investigated the characteristics of MDDS patients with vestibular migraine (MDDS-VM) to those without (MDDS-O). STUDY DESIGN Retrospective review. METHODS Retrospective, single-center study of 62 patients with MDDS. Clinical characteristics, Dizziness Handicap Inventory (DHI), Migraine Disability Assessment Score (MIDAS), job impact, and optimal treatment(s) were studied. RESULTS There were 23 MDDS-O (19 women), and 39 MDDS-VM (35 women) patients. Comparisons between MDDS-VM and MDDS-O showed significant differences in age of onset (41 vs. 52 years, P = .005), interictal visually induced dizziness (89.7% vs. 30.4%, P < .001), interictal head motion-induced dizziness (87.2% vs. 47.8%, P = .001), other vestibular sensations (59% vs. 13%, P < .001), interictal aural symptoms (25.6% vs. 0%, P = .008), number of interictal symptoms (4.3 vs. 2.3, P < .001), total DHI score (54.9 vs. 38.1, P = .005), DHI-P (physical domain) score (16.1 vs. 10, P = .004), DHI-F (functional domain) score (20.9 vs. 15.7, P = .016 MIDAS (4.6 vs. 32, P = .002), and job resignations (23.2% vs. 5%, P = .016). On the other hand, between-group comparisons for MT-MDDS and SO-MDDS did not reveal any significant differences whatsoever. For optimal treatment, venlafaxine was the most used (27.3%) in all groups. For MDDS-VM, antiepileptic drugs and migraine preventive vitamins were also useful in relieving symptoms. CONCLUSIONS MDDS-VM patients appear to be more disabled than MDDS-O, in terms of severity of dizziness, job impact, and number of symptoms, but have good potential for improvement, particularly with migraine prophylactic treatment. LEVEL OF EVIDENCE 3 Laryngoscope, 131:E1653-E1661, 2021.
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Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Hsueh-Sheng Chiang
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
| | - Collin Sanderson
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A
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Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center , Dallas, TX, USA
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Beh SC. Noninvasive Vagus Nerve Stimulation for Nausea Prevention During BPPV Treatment. Neuromodulation 2020; 23:886-887. [DOI: 10.1111/ner.13129] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2019] [Revised: 01/15/2020] [Accepted: 02/03/2020] [Indexed: 11/29/2022]
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Beh SC. External trigeminal nerve stimulation: Potential rescue treatment for acute vestibular migraine. J Neurol Sci 2019; 408:116550. [PMID: 31677559 DOI: 10.1016/j.jns.2019.116550] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 10/19/2019] [Accepted: 10/21/2019] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Vestibular migraine (VM) is the most common neurologic cause of vertigo among adults. However, there are no specifically studied or approved rescue therapies for acute VM attacks. This study describes how external trigeminal nerve stimulation (eTNS) using the Cefaly® (CEFALY Technology, Seraing, Belgium) device relieves acute VM episodes. METHODS Single-center, retrospective review of 19 patients with acute VM attacks (seen between May 2018 and June 2019) treated with 20-min eTNS. Prior to treatment, patients graded the severity of their vertigo/headache using a 10-point visual analog scale (VAS) with 0 representing no vertigo/headache, and 10 representing the worst imaginable vertigo/headache. After eTNS, patients graded their vertigo/headache using the same VAS 15 min. In addition, bedside neuro-otologic examination was performed before and after treatment. RESULTS 19/19 patients reported improvement in vertigo severity. Mean vertigo severity was 6.6 (±2.1; median 7) before eTNS, and 2.7 (±2.6; median 3) following treatment; mean improvement in vertigo was 61.3% (±32.6; median 50.0%). During VM episodes, 14/19 experienced headache. Mean headache severity was 4.8 (±2.4; median 4.5) before eTNS, and was 1.4 (±2.4; median 0) following treatment; mean improvement in headache was 77.2% (±32.7; median 100.0%). Neuro-otologic examination was normal during VM attacks in all except Patient 7 who had spontaneous upbeat nystagmus which resolved after eTNS. Other improvements include improvement of eye pressure, head pressure, and chronic facial pain. No intolerable side effects were reported. CONCLUSION This study provides preliminary evidence that eTNS is a novel, non-invasive, safe and effective treatment for acute VM attacks.
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Affiliation(s)
- Shin C Beh
- Department of Neurology, UT Southwestern Medical Center, United States of America.
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Beh SC, Friedman DI. Acute vestibular migraine treatment with noninvasive vagus nerve stimulation. Neurology 2019; 93:e1715-e1719. [DOI: 10.1212/wnl.0000000000008388] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/29/2019] [Indexed: 11/15/2022] Open
Abstract
ObjectiveTo report on the benefits of noninvasive vagus nerve stimulation (nVNS) on acute vestibular migraine (VM) treatment.MethodsThis was a retrospective chart review of patients with VM treated with nVNS in a single tertiary referral center between November 2017 and January 2019. Eighteen patients (16 women) were identified (mean age 45.7 [±14.8] years); 14 were treated for a VM attack and 4 for bothersome interictal dizziness consistent with persistent perceptual postural dizziness (PPPD). Patients graded the severity of vestibular symptoms and headache using an 11-point visual analog scale (VAS; 0 = no symptoms, 10 = worst ever symptoms) before and 15 minutes after nVNS.ResultsIn those with acute VM, vertigo improved in 13/14 (complete resolution in 2, at least 50% improvement in 5). The mean vertigo intensity before nVNS was 5.2 (±1.6; median 6), and 3.1 (±2.2; median 3) following stimulation; mean reduction in vertigo intensity was 46.9% (±31.5; median 45%). Five experienced headache with the VM attack; all reported improvement following nVNS. Mean headache severity was 6 (±1.4; median 6) prior to treatment and 2.4 (±1.5; median 3) following nVNS; mean reduction in headache intensity was 63.3% (±21.7; median 50). All 4 treated with nVNS for interictal PPPD reported no benefit.ConclusionOur study provides preliminary evidence that nVNS may provide rapid relief of vertigo and headache in acute VM, and supports further randomized, sham-controlled studies into nVNS in VM.Classification of evidenceThis study provides Class IV evidence that for patients with acute VM, nVNS rapidly relieves vertigo and headache.
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Beh SC. Horizontal Direction-Changing Positional Nystagmus and Vertigo: A Case of Vestibular Migraine Masquerading as Horizontal Canal BPPV. Headache 2019; 58:1113-1117. [PMID: 30152162 DOI: 10.1111/head.13356] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/28/2018] [Indexed: 11/28/2022]
Abstract
Episodic positional vertigo is typically due to benign paroxysmal positional vertigo (BPPV) but may also be a manifestation of vestibular migraine. Distinguishing vestibular migraine from BPPV is essential since the treatment of each disorder is markedly different. The 31-month clinical course of a 41-year-old woman with vestibular migraine causing recurrent positional vertigo is described. During vestibular migraine attacks, she developed left-beating nystagmus in the upright position with removal of fixation, and geotropic horizontal nystagmus during the supine roll test. Interictally, her exam demonstrated positional apogeotropic horizontal nystagmus with the supine roll test, more intense in the supine head left position. Her vestibular migraine was successfully controlled with topiramate and eletriptan.
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Affiliation(s)
- Shin C Beh
- Department of Neurology & Neurotherapeutics, Division of Headache Medicine, University of Texas Southwestern Medical Center at Dallas, Dallas, TX, USA
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Beh SC. The “eye of the tiger” in a patient with multiple sclerosis. J Neurol Sci 2019; 399:1-2. [DOI: 10.1016/j.jns.2019.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 01/03/2019] [Accepted: 02/01/2019] [Indexed: 11/25/2022]
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Conger D, Beh SC. Seeing function in structure: "incidental" eye findings on OCT in a patient with multiple sclerosis. Mult Scler Relat Disord 2019; 31:72-73. [PMID: 30947064 DOI: 10.1016/j.msard.2019.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/26/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022]
Abstract
A 17-year-old girl with relapsing-remitting multiple sclerosis (MS) was referred for a 2-year history of visual blurriness. Her bedside examination was remarkable for gait unsteadiness only. Optical coherence tomography was performed as part of her workup. Unexpectedly, Spectralis© video imaging revealed left torsional nystagmus that was not apparent on bedside examination. Review of previous brain magnetic resonance images (MRI) revealed left ocular deviation, as well as a left dorsolateral medullary MS plaque, which was the cause of her torsional nystagmus. We highlight how Spectralis© scanning confocal laser ophthalmoscopy allows video imaging that can capture torsional ocular movements.
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Affiliation(s)
- Darrel Conger
- Department of Neurology & Neurotherapeutics, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas TX 75390, United States
| | - Shin C Beh
- Department of Neurology & Neurotherapeutics, UT Southwestern Medical Center at Dallas, 5323 Harry Hines Blvd, Dallas TX 75390, United States.
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Al-Louzi O, Sotirchos ES, Vidal-Jordana A, Beh SC, Button J, Ying HS, Balcer LJ, Frohman EM, Saidha S, Calabresi PA, Newsome SD. Characteristics of morphologic macular abnormalities in neuroimmunology practice. Mult Scler 2019; 25:361-371. [PMID: 29125422 PMCID: PMC6929206 DOI: 10.1177/1352458517741206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Morphologic macular abnormalities (MMAs) are frequently seen on macular optical coherence tomography (OCT) imaging in neuroimmunology practice, yet studies pragmatically assessing prevalence and risk factors of MMAs to date are limited. OBJECTIVE To describe the characteristics of MMAs in a neuroimmunology-based academic practice. METHODS Cross-sectional study of 1450 patients (2900 eyes) who underwent spectral-domain macular OCT between June 2010 and June 2012. The association between MMAs and demographic variables was analyzed using mixed-effects logistic regression. Odds ratios (ORs) were calculated per 5-year age increments. RESULTS MMAs were observed in 338/2872 eyes (11.7%) of 232/1445 participants (16.1%). The most common abnormalities identified, included drusen (6.0%), epiretinal membrane (ERM; 5.5%), and microcystoid macular pathology (MMP; 1.9%). Overall, patients with MMAs were older (OR: 1.79, p = 5 × 10-5) and more likely to be males (OR: 2.45, p = 0.014). In particular, advancing age was associated with higher risk of drusen and ERM (OR: 1.80 and 4.26, p = 2 × 10-5 and 7 × 10-3, respectively). MMP prevalence declined with age (OR: 0.73, p = 0.015) and was associated with African-American ethnicity (OR: 15.0, p = 5 × 10-5). CONCLUSION Unexpected or incidental MMAs are common in patients assessed with OCT in neuroimmunology practice, emphasizing the importance of comprehensive OCT image review for risk stratification and appropriate ophthalmology referral.
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Affiliation(s)
- Omar Al-Louzi
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
| | - Elias S. Sotirchos
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
| | - Angela Vidal-Jordana
- Department of Neurology-Neuroimmunology and Multiple Sclerosis Centre of Catalonia (Cemcat), Edifici Cemcat, Hospital Universitari Vall d’Hebron, Universitat Autònoma de Barcelona
| | - Shin C. Beh
- Department of Neurology and Ophthalmology, University of Texas Southwestern, Dallas, TX, USA
| | - Julia Button
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
| | - Howard S. Ying
- Department of Ophthalmology, Boston Medical Center, Boston, MA 02118
| | - Laura J. Balcer
- Departments of Neurology, Population Health and Ophthalmology, New York University School of Medicine, New York, NY, USA
| | - Elliot M. Frohman
- Department of Neurology and Ophthalmology, University of Texas Southwestern, Dallas, TX, USA
| | - Shiv Saidha
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
| | - Peter A. Calabresi
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
| | - Scott D. Newsome
- Division of Neuroimmunology and Neurological Infections, Department of Neurology, Johns Hopkins hospital, Baltimore, MD 21287
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Beh SC, Masrour S, Smith SV, Friedman DI. The Spectrum of Vestibular Migraine: Clinical Features, Triggers, and Examination Findings. Headache 2019; 59:727-740. [DOI: 10.1111/head.13484] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Shin C. Beh
- Department of Neurology UT Southwestern Medical Center Dallas TX USA
| | - Shamin Masrour
- Department of Neurology UT Southwestern Medical Center Dallas TX USA
| | - Stacy V. Smith
- Department of Neurology Houston Methodist Neurological Institute Houston TX USA
| | - Deborah I. Friedman
- Department of Neurology UT Southwestern Medical Center Dallas TX USA
- Department of Ophthalmology UT Southwestern Medical Center Dallas TX USA
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Beh SC, Masrour S, Smith SV, Friedman DI. Clinical characteristics of Alice in Wonderland syndrome in a cohort with vestibular migraine. Neurol Clin Pract 2018; 8:389-396. [PMID: 30564492 PMCID: PMC6276353 DOI: 10.1212/cpj.0000000000000518] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 06/29/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Alice in Wonderland syndrome (AIWS) is a rare sensory perception disorder, most often caused by migraine in adults. We aimed to characterize the clinical characteristics of AIWS in a cohort of vestibular migraine (VM) patients. METHODS Retrospective chart review of patients diagnosed with VM seen between August 2014 and January 2018. RESULTS Seventeen patients were identified (10 women) with a median age at onset of 45 years (range 15-61 years), and median age at presentation of 49 years (range 17-63 years). Eighty-two percent reported 1 AIWS symptom, 12% reported 3 symptoms, and 6% described 2 symptoms. The most common symptom was visual distortions (47%), followed by extrapersonal misperceptions (41%) and somesthetic distortions (29%). Most AIWS occurred during VM episodes (77%). Eleven patients were seen in follow-up; 10 described complete or partial resolution of both AIWS and VM with migraine preventive therapy, while 1 experienced complete resolution of VM but continued to have AIWS. Neuro-otologic abnormalities improved in 2 patients. CONCLUSIONS This study characterizes the clinical features of AIWS in patients with VM. We observed several rare and highly unusual AIWS misperceptions (frosted-glass vision, underwater vision, dolly zoom effect, sensation of the brain coming out of the head, closed-eye visual hallucinations, and headlight glare-induced marco/microsomatognosia), and resolution or improvement in AIWS and VM with migraine preventive treatment.
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Affiliation(s)
- Shin C Beh
- Departments of Neurology (SCB, SM, DIF) and Ophthalmology (DIF), University of Texas Southwestern Medical Center at Dallas; and Department of Neurology (SVS), Houston Methodist Neurological Institute, TX
| | - Shamin Masrour
- Departments of Neurology (SCB, SM, DIF) and Ophthalmology (DIF), University of Texas Southwestern Medical Center at Dallas; and Department of Neurology (SVS), Houston Methodist Neurological Institute, TX
| | - Stacy V Smith
- Departments of Neurology (SCB, SM, DIF) and Ophthalmology (DIF), University of Texas Southwestern Medical Center at Dallas; and Department of Neurology (SVS), Houston Methodist Neurological Institute, TX
| | - Deborah I Friedman
- Departments of Neurology (SCB, SM, DIF) and Ophthalmology (DIF), University of Texas Southwestern Medical Center at Dallas; and Department of Neurology (SVS), Houston Methodist Neurological Institute, TX
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Beh SC. A Case of Vestibular Migraine Resolving on Warfarin and Topiramate. Headache 2018; 58:599-600. [DOI: 10.1111/head.13266] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/10/2018] [Accepted: 01/11/2018] [Indexed: 11/28/2022]
Affiliation(s)
- Shin C. Beh
- Department of Neurology; University of Texas Southwestern Medical Center at Dallas; Dallas TX USA
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Beh SC, Kildebeck E, Narayan R, Desena A, Schell D, Rowe ES, Rowe V, Burns D, Whitworth L, Frohman TC, Greenberg B, Frohman EM. High-dose methotrexate with leucovorin rescue: For monumentally severe CNS inflammatory syndromes. J Neurol Sci 2017; 372:187-195. [DOI: 10.1016/j.jns.2016.11.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2016] [Revised: 10/20/2016] [Accepted: 11/07/2016] [Indexed: 11/30/2022]
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Nolan R, Narayana K, Beh SC, Rucker JC, Balcer LJ, Galetta SL. Utility of optical coherence tomography in the evaluation of monocular visual loss related to retinal ischemia. J Clin Neurosci 2016; 26:116-21. [DOI: 10.1016/j.jocn.2015.10.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 09/03/2015] [Accepted: 10/25/2015] [Indexed: 11/27/2022]
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Beh SC. Review of Eye Movement Disorders in Clinical Practice. JAMA Neurol 2015. [DOI: 10.1001/jamaneurol.2015.1707] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Shin C. Beh
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas
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Zee DS, Beh SC, Kheradmand A. Author response. Neurology 2014; 83:1879. [PMID: 25544981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2023] Open
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Affiliation(s)
- Shin C Beh
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA; Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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Beh SC, Muthusamy B, Calabresi P, Hart J, Zee D, Patel V, Frohman E. Hiding in plain sight: a closer look at posterior cortical atrophy. Pract Neurol 2014; 15:5-13. [DOI: 10.1136/practneurol-2014-000883] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Affiliation(s)
- Shin C. Beh
- Department of Neurology, New York University School of Medicine, New York2Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas
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Schnurman ZS, Frohman TC, Beh SC, Conger D, Conger A, Saidha S, Galetta S, Calabresi PA, Green AJ, Balcer LJ, Frohman EM. Retinal architecture and mfERG: Optic nerve head component response characteristics in MS. Neurology 2014; 82:1888-96. [PMID: 24789865 DOI: 10.1212/wnl.0000000000000447] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To describe a novel neurophysiologic signature of the retinal ganglion cell and to elucidate its relationship to abnormalities in validated structural and functional measures of the visual system. METHODS We used multifocal electroretinogram-generated optic nerve head component (ONHC) responses from normal subjects (n = 18), patients with multiple sclerosis (MS) (n = 18), and those with glaucoma (n = 3). We then characterized the relationship between ONHC response abnormalities and performance on low-contrast visual acuity, multifocal visual-evoked potential-induced cortical responses, and average and quadrant retinal nerve fiber layer (RNFL) thicknesses, as measured by spectral-domain optical coherence tomography. RESULTS Compared with the eyes of normal subjects, the eyes of patients with MS exhibited an increased number of abnormal or absent ONHC responses (p < 0.0001). For every 7-letter reduction in low-contrast letter acuity, there were corresponding 4.6 abnormal ONHC responses at 2.5% contrast (p < 0.0001) and 6.6 abnormalities at the 1.25% contrast level (p < 0.0001). Regarding average RNFL thickness, for each 10-μm thickness reduction, we correspondingly observed 6.8 abnormal ONHC responses (p = 0.0002). The most robust association was between RNFL thinning in the temporal quadrant and ONHC response abnormalities (p < 0.0001). CONCLUSION Further characterization of ONHC abnormalities (those that are reversible and irreversible) may contribute to the development of novel neurotherapeutic strategies aimed at achieving neuroprotective, and perhaps even neurorestorative, effects in disorders that target the CNS in general, and MS in particular.
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Affiliation(s)
- Zane S Schnurman
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Teresa C Frohman
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Shin C Beh
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Darrel Conger
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Amy Conger
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Shiv Saidha
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Steven Galetta
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Peter A Calabresi
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Ari J Green
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco
| | - Laura J Balcer
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco.
| | - Elliot M Frohman
- From the Departments of Neurology (Z.S.S., T.C.F., S.C.B., D.C., A.C., E.M.F.) and Ophthalmology (E.M.F.), University of Texas Southwestern Medical Center at Dallas; Department of Neurology (S.S., P.A.C.), Johns Hopkins Hospital, Baltimore, MD; Department of Neurology (S.S.), Beaumont University Hospital, Dublin, Ireland; Department of Neurology (S.G., L.J.B.), New York University Langone Medical Center; and Departments of Neurology (A.J.G.) and Ophthalmology (A.J.G.), University of California at San Francisco.
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Abstract
Acquired pendular nystagmus (PN) occurs commonly in multiple sclerosis (MS) and results in a highly disabling oscillopsia that impairs vision. It usually consists of pseudo-sinusoidal oscillations at a single frequency (3-5 Hz) that often briefly stop for a few hundred milliseconds after saccades and blinks. The oscillations are thought to arise from instability in the gaze-holding networks ("neural integrator") in the brainstem and cerebellum.(1,2) Here we describe a patient with monocular PN in whom vibration on the skull from a handheld muscle massager strikingly diminished or stopped her nystagmus.
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Affiliation(s)
- Shin C Beh
- From The Johns Hopkins Hospital, Baltimore, MD
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Abstract
Neurology is a field known for "eponymophilia." While eponym use has been a controversial issue in medicine, animal-related metaphoric descriptions continue to flourish in neurologic practice, particularly with the advent of neuroimaging. To provide practicing and trainee neurologists with a useful reference for all these colorful eponyms, we performed a literature review and summarized the various animal eponyms in the practice of neurology (and their etiologic implications) to date. We believe that the ability to recognize animal-like attributes in clinical neurology and neuroradiology may be attributed to a visual phenomenon known as pareidolia. We propose that animal eponyms are a useful method of recognizing clinical and radiologic patterns that aid in the diagnostic process and therefore are effective aidesmémoire and communicative tools that enliven and improve the practice of neurology.
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Affiliation(s)
- Shin C Beh
- Department of Neurology (SCB, TF, EMF) and Ophthalmology (EMF), University of Texas Southwestern Medical Center, Dallas, TX
| | - Teresa Frohman
- Department of Neurology (SCB, TF, EMF) and Ophthalmology (EMF), University of Texas Southwestern Medical Center, Dallas, TX
| | - Elliot M Frohman
- Department of Neurology (SCB, TF, EMF) and Ophthalmology (EMF), University of Texas Southwestern Medical Center, Dallas, TX
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Beh SC, Frohman TC, Frohman EM. Isolated mammillary body involvement on MRI in Wernicke's encephalopathy. J Neurol Sci 2013; 334:172-5. [DOI: 10.1016/j.jns.2013.07.2516] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2013] [Revised: 07/24/2013] [Accepted: 07/26/2013] [Indexed: 10/26/2022]
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Affiliation(s)
- Shin C. Beh
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Benjamin M. Greenberg
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Teresa Frohman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
| | - Elliot M. Frohman
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
- Department of Ophthalmology, University of Texas Southwestern Medical Center, 5323, Harry Hines Blvd, Dallas, TX 75390, USA
- Corresponding author. Multiple Sclerosis Clinical Care Center, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75235.
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Affiliation(s)
- Shin C Beh
- Departments of Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center at Dallas, USA.
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