Simple answer, “Yes.”
In addition to typical focal headaches, many migraineurs also experience photophobia, phonophobia, and/or osmophobia, both during and between headache episodes. Many migraineurs describe sensory hypersensitivity which results in common everyday situations being intolerable. Lights are too bright, sounds are too loud, smells are too strong.
Most of us can relate the discomfort of having a bright light directed at you, or the annoyance of nearby construction noise, or the nausea induced by the sweet old lady that has become unaware of the strength of her cheap perfume, or the young dude figuring out how much Axe body spray is too much. Migraineurs often experience this same discomfort in situations most of us encounter daily. Their threshold for discomfort is reduced to the point of being potentially disabling and has significant negative impact on quality of life.
This same low threshold phenomena can apply to self- motion or external visual motion. Migraineurs are roughly twice as likely to report motion sensitivity compared to non-migraineurs. Many report discomfort triggered by scrolling on a phone or flickering lights in their periphery.
Sensory Hypersensitivity versus Sensory Conflict
Sensory conflict is more difficult to recognize and describe compared to sensory hypersensitivity, but it also affects a large number of migraineurs. A sensory conflict occurs when one sensory input (for example the inner ears) receives information that conflicts with another sensory input (vision or proprioception).
A familiar example of this can occur when stopped at a red light. Envision a large truck in the next lane moving forward while you are still. There is a fleeting foot on the brake and grip of the wheel until your sensory system determines the truck is moving forward rather than you rolling backward. This conflict is easily managed by most of us, but a migraineur can overreact and this conflict can be a trigger for a variety of symptoms.
Steenerson and Fife describe that these symptoms can include: “disorientation (dizziness, unsteadiness, lightheadedness, vertigo), gastric (nausea, vomiting), autonomic (sweating, pallor) arousal (fatigue, difficulty concentrating, brain fog).” I will add anxiety and panic attack to the list.
BPPV as the Ultimate Sensory Conflict
A number of studies have reported that migraineurs suffer from greater degrees of nausea and subjective vertigo during caloric testing compared to non-migraineurs, despite there being no difference in nystagmus intensity.
Caloric irrigation presents a transient sensory conflict (typically lasting about one minute) due to temperature induced changes in endolymph density. By performing this in one ear at a time, a significant asymmetry in labyrinthine output is achieved. During a typical BPPV episode, there is a transient spike in excitatory stimulation of the affected canal, also resulting in transient asymmetric labyrinthine output.
In both of these situations, the brain is receiving a message that one ear is moving, but the other is not. Can you think of a more dramatic sensory conflict?
What About Residual Dizziness?
Migraineurs are more likely to report residual dizziness, even after the positional vertigo episodes and nystagmus responses are resolved. Some have posed theories that residual dizziness may be the result of lingering loose otoconia, or other remaining vestibular dysfunction.
One theory worth considering is that migraineurs overreact to the intense symptoms with a version of cerebellar clamp, which affects the Vestibular Ocular Reflex as part of a “compensation” process. There is evidence that longer duration of untreated BPPV correlates with higher likelihood of residual dizziness, not just in migraineurs.
This suggests that the brain adapts (compensates) to repeated transient bouts of conflicting labyrinthine signals and needs time to adjust back once the offending stimulus (vertigo and nystagmus) is resolved.
Want More?
The following article published in May, 2024 explores BPPV symptoms on a group of migraineurs compared to a group of non-migraineurs, concluding:
“…at both the diagnosis and on one month follow-up for BPPV, patients with migraine experienced more severe symptoms and a greater adverse impact on their quality of life compared to those without migraine.”
Bottom Line?
If a patient’s symptoms seem to be out of proportion with the intensity of nystagmus, or continue to complain of lingering dizziness once the BPPV is resolved, inquire about a history of migraine.
Better yet, make this part of your standard interview so you can manage patient expectations better.
About the author
Alan Desmond, AuD, is the director of the Balance Disorders Program at Wake Forest Baptist Health Center, and holds an adjunct assistant professor faculty position at the Wake Forest School of Medicine. He has written several books and book chapters on balance disorders and vestibular function. He is the co-author of the Clinical Practice Guideline for Benign Paroxysmal Positional Vertigo (BPPV). In 2015, he was the recipient of the President’s Award from the American Academy of Audiology.
