Vestibular Migraine (Part III)

By Christa Browning

(Editor’s note: This paper was submitted by Ms. Browning as a class assignment and is reprinted exactly as submitted. Therefore, the referencing style is different from the format typically used at Hearinghealthmatters.org)

INTRODUCTION

The connection between migraine and vertigo has been recognized and documented by neurologists dating back to the 19th century. However, only recently has “vestibular migraine” been added to the International Headache Society as the correct diagnostic name for this disorder {{1}}[[1]]Hain, T. C., Migraine associated vertigo (MAV) – vestibular migraine (MV). Retrieved from http://www.dizziness-and-balance.com/disorders/central/migraine/mav.html[[1]] vestibular migraine, also previously known as migraine-associated vertigo or migrainous vertigo, is a very common cause of dizziness in adults, affecting about 1.1% of the general population {{2}}[[2]]Fotuhi, M., Glaun, B., Quan, S. Y., & Sofare, T. (2009). Vestibular migraine: a critical review of treatment trials. Journal of Neurology, 256, 711-716[[2]]. Despite the commonality of this disorder, it has been estimated that about 50% of these individuals go undiagnosed or are given inappropriate treatment options .{{3}}[[3]]Kramer, J., & Buskirk, J. (2013). Migraine associated vertigo [PDF document]. Retrieved from https://vestibular.org/sites/default/files/page_files/Migraine%20Associated%20Vertigo_1.pdf[[3]]

Symptoms

Although a patient with vestibular migraine may experience migrainous and vestibular symptoms together, it is also possible for the patient to have vestibular symptoms separate from migraine. The symptoms of this disorder are quite varied, and may last from a few seconds to days.

Migraine is believed to be the result of a combination of an enlargement of certain blood vessels in the brain and the release of certain chemicals that are responsible for inflammation and pain (Desmond, A., 2011). It is typically characterized by unilateral onset of head pain that progressively intensifies, possibly throbbing or pounding, and interfering with the patient’s lifestyle, nausea and/or vomiting, photophobia (sensitivity to light), and phonosensitivity (intolerance to noise) are possible symptoms that may be experienced as well {{3}}[[3]]Kramer, J., & Buskirk, J. (2013). Migraine associated vertigo [PDF document]. Retrieved from https://vestibular.org/sites/default/files/page_files/Migraine%20Associated%20Vertigo_1.pdf .[[3]]

The symptoms related to the vestibular aspect of this disorder include but aren’t limited to “dizziness, motion intolerance with respect to head, eyes, and/or body, spontaneous vertigo attacks (accompanied by nausea and vomiting), diminished eye focus with photosensitivity, sound sensitivity and tinnitus, balance loss and ataxia, neck pain with associated muscle spasms in the upper cervical spine musculature, confusion with altered cognition, spatial disorientation, and anxiety/panic” .{{3}}[[3]]Kramer, J., & Buskirk, J. (2013). Migraine associated vertigo [PDF document]. Retrieved from https://vestibular.org/sites/default/files/page_files/Migraine%20Associated%20Vertigo_1.pdf[[3]] The patient typically experiences sudden onset of the vertigo, most often rotary but could also include positional. The quality of life for the patient is often decreased as well.

Food and environmental triggers can bring on the episodes of these symptoms for many patients. These triggers overlap with ones that are specific to patients with migraine. Weather changes and hormonal fluctuations often bring on both migraine and vestibular conditions. Irregular sleep, stress, physical exertion, medications and dehydration may also induce symptoms of this disorder. Some foods that may trigger these episodes include but aren’t limited to: aged or ripened cheese; foods containing large amounts of MSG; alcohol, especially red wine; and excessive tea, coffee, or cola.

 

Exam Profile

There is no specific diagnostic test for vestibular migraine. Vestibular migraine is commonly diagnosed by using a very detailed case history of the patient and ruling out other vestibular disorders. Several professionals have used different, yet similar criteria to diagnose vestibular migraine. As stated by Desmond in Vestibular Function: Clinical and Practice Management (2011), “Cass et al. (1997) uses the following criteria for establishing a diagnosis: (1) history of migraine headaches, (2) family history of migraine, (3) history of space and motion intolerance, and (4) vestibular symptoms that do not fit other common vestibular disorders” (p.45). Hain {{1}}[[1]]Hain, T. C., (2013). Migraine associated vertigo (MAV) – vestibular migraine (MV). HAIN uses criteria similar to the one mentioned previously with the addition of the patient responding to migraine medication. The International Headache Society recently published their criteria for diagnosing vestibular migraine (Lembert, T., 2013):

(A) At least 5 episodes with vestibular symptoms or moderate or severe intensity, lasting 5 min to 72 hr
(B) Current or previous history of migraine with or without aura according to the International Classification of Headache Disorders (ICHD)
(C) One or more migraine features with at least 50% of the vestibular episodes:
a. Headache with at least two of the following characteristics: one-sided location, pulsating quality, moderate or severe pain intensity,   aggravation by routine physical activity
b. Photophobia and phonophobia
c. Visual aura

(D) Not better accounted for by another vestibular or ICHD diagnosis

Vestibular function testing can assist in ruling out other vestibular disorders. There have been some patterns within these function tests that correspond with, but do not diagnose, vestibular migraine. The patterns according to Hain (2013) include: ENG inner ear testing in vestibular migraine is normal, but a low-level positional nystagmus is very common, along with more downbeating upright; hearing testing is generally normal but can sometimes have bilateral reduction of hearing at low frequencies; and there is often an increased VOR time constant on rotational chair testing. Other test patterns may include: hyperactive caloric response or a strong vegetative response (migrainous patients are four times more likely to experience nausea/vomiting); long-time constants on step velocity tests (5); and abnormal smooth pursuit tests (must be distinguished from expected age-related changes) {{3}}[[3]]Kramer, J., & Buskirk, J. (2013). Migraine associated vertigo [PDF document]. Retrieved from https://vestibular.org/sites/default/files/page_files/Migraine%20Associated%20Vertigo_1.pdf[[3]]  

Prevention & Treatment Options

A combination of medication, lifestyle modifications, and vestibular rehabilitation is believed to have the highest effectiveness in the management of vestibular migraine. Prevention is the most advised treatment for vestibular migraine. By modifying the patient’s lifestyle to avoid triggers such as certain foods, making sure that the patient is getting an adequate amount of sleep, and is not over stressed, vestibular migraine could possibly be prevented.
When modifying lifestyle is unsuccessful, medication and vestibular rehabilitation is recommended. Medications such as beta-blockers, antidepressants, calcium channel blockers, anticonvulsants, and carbonic anhydrase inhibitors can assist in the prevention and treatment of vestibular migraine. It is essential that the patient’s progress be noted regularly while on these medications to ensure the efficacy of the medication. The patient’s overall health status should be monitored as well, as some medications may cause weight gain and hypertension. Vestibular rehabilitation such as gaze-stability exercises, stretching, and postural instability and gait alteration exercises is well documented to reduce symptoms and restore function for vestibular-related disorders.References

1. Hain, T. C., (2013). Migraine associated vertigo (MAV) – vestibular migraine (MV). Retrieved from http://www.dizziness-and-balance.com/disorders/central/migraine/mav.html

2. Fotuhi, M., Glaun, B., Quan, S. Y., & Sofare, T. (2009). Vestibular migraine: a critical review of treatment trials. Journal of Neurology, 256, 711-716.

3. Kramer, J., & Buskirk, J. (2013). Migraine associated vertigo [PDF document]. Retrieved from https://vestibular.org/sites/default/files/page_files/Migraine%20Associated%20Vertigo_1.pdf
4. Desmond, A. (2011). Vestibular Function: Clinical and Practice Management. New York, NY: Thieme Medical Publishers, Inc

5. Cass et al (1997) Migraine related vestibulopathy. Ann Otol Rhinol Laryngol 106(3): 182-9.
http://www.ncbi.nlm.nih.gov/pubmed/?term=1997)+Migraine+related+vestibulopathy

6. Lempert, T. (2013). Vestibular migraine. Seminars in Neurology, 33, 212-218.

About Alan Desmond

Dr. Alan Desmond 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. In 2015, he received the Presidents Award from the American Academy of Audiology.