Migraine-associated vertigo

Vestibular migraine (VM) is vertigo associated with a migraine, either as a symptom of migraine or as a related but neurological disorder; when referred to as a disease unto itself.

Migraine-associated vertigo
Other namesMigraine-associated vertigo (MAV), Migrainous vertigo, Migraine-related vestibulopathy.
SpecialtyNeurology

A 2010 report from the University of British Columbia published in the journal Headache said that it "... is emerging as a popular diagnosis for patients with recurrent vertigo. Even though some authors believe that 'migraine associated vertigo,' is neither clinically nor biologically plausible as a migraine variant."[1] Epidemiological studies leave no doubt that there is a strong link between vertigo and migraine.[2]

Signs and symptoms

Vertigo is a medically recognized term for the symptom of a vestibular system disturbance. It may include a feeling of rotation or illusory sensations of motion or both. The general term dizziness is used by nonmedical people for those symptoms but often refers to a feeling of light-headedness, giddiness, drowsiness, or faintness, all of which must be differentiated from true vertigo,[3] since the latter symptoms might have other causes.

Motion sickness occurs more frequently in migraine patients (30–50% more than in controls).[4] Benign paroxysmal vertigo of childhood is an example of migraine-associated vertigo in which headache does not often occur.[5] Basilar artery migraine (BAM) consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields or both eyes, diplopia, bilateral paresthesias, paresis, decreased consciousness and/or loss of consciousness) followed by throbbing headache. Auditory symptoms are rare. However, a study showed a fluctuating low-tone sensorineural hearing loss in more than 50% of patients with BAM with a noticeable change in hearing just before the onset of a migraine headache. The attacks of vertigo are usually concurrent with a headache and the family history is usually positive. The diagnostician must rule out: TIAs, and paroxysmal vestibular disorder accompanied by headache.

There is also a familial vestibulopathy, familial benign recurrent vertigo (fBRV), where episodes of vertigo occur with or without a migraine headache. Testing may show profound vestibular loss. The syndrome responds to acetazolamide. Familial hemiplegic migraine (FHM) has been linked to mutations in the calcium channel gene. (Ophoff et al. 1966 cf. Lempert et al.)[5]

Pathophysiology

The pathophysiology of MAV is not completely understood; both central and peripheral defects have been observed.[6]

Diagnosis

MAV is not recognized as a distinct diagnostic entity.[7] Lembert and Neuhauser propose criteria for definite and probable migraine-associated vertigo.[3]

A diagnosis of definite migraine-associated vertigo includes a case history of:

A diagnosis of probable migraine-associated vertigo includes a case history of episodic vestibular symptoms of at least moderate severity and one of the following:

  • current or previous history of migraine according to the 2004 International Classification of Headache Disorders;
  • migrainous symptoms during vestibular symptoms;
  • migraine precipitants of vertigo in more than 50% of attacks, such as food triggers, sleep irregularities, or hormonal change;
  • response to migraine medications in more than 50% of attacks; and
  • other causes ruled out by appropriate investigations.

Note that, in both of the above criteria, headache is not required to make the diagnosis of migraine-associated vertigo.[3][8]

They add that, in patients with a clear-cut history, no vestibular tests are required. Other historical criteria which are helpful in making the diagnosis of migraine-associated vertigo are vertiginous symptoms throughout the patient’s entire life, a long history of motion intolerance, sensitivity to environmental stimuli, illusions of motion of the environment, and vertigo that awakens the patient.[8]

Classification

Benign paroxysmal positional vertigo - Migraine is commonly associated with BPPV, the most common vestibular disorder in patients presenting with dizziness. The two may be linked by genetic factors or by vascular damage to the labyrinth.[5]

Ménière's disease - There is an increased prevalence of migraine in patients with Ménière's disease and migraine leads to a greater susceptibility of developing Ménière’s disease. But they can be distinguished. Ménière's disease may go on for days or even years, while migraines typically do not last longer than 24 hours.[5]

Motion sickness is more prevalent in patients with migraine.[5]

Psychiatric syndromes Dizziness and spinning vertigo are the second most common symptom of panic attacks, and they can also present as a symptom of major depression. Migraine is a risk factor for developing major depression and panic disorder and vice versa.[5]

Treatment

Treatment of migraine-associated vertigo is the same as the treatment for migraine in general.[9] There is not enough evidence to indicate which medications are most effective for preventing vestibular migraine.[10]

Epidemiology

The prevalence of migraine and vertigo is 1.6 times higher in 200 dizziness clinic patients than in 200 age- and sex-matched controls from an orthopaedic clinic. Among the patients with unclassified or idiopathic vertigo, the prevalence of migraine was shown to be elevated. In another study, migraine patients reported 2.5 times more vertigo and also 2.5 more dizzy spells during headache-free periods than the controls.[5]

MAV may occur at any age with a female:male ratio of between 1.5 and 5:1. Familial occurrence is not uncommon. In most patients, migraine headaches begin earlier in life than MAV with years of headache-free periods before MAV manifests.[5]

In a diary study, the 1-month prevalence of MAV was 16%, frequency of MAV was higher and duration longer on days with headache, and MAV was a risk factor for co-morbid anxiety.[11]

References
  1. Phillips J, Longridge N, Mallinson A, Robinson G (August 2010). "Migraine and Vertigo: A Marriage of Convenience?". Headache. 50 (8): 1362–1365. doi:10.1111/j.1526-4610.2010.01745.x. PMID 20738416.
  2. von Brevern, M; Baloh RW; Bisdorff A; Brandt T; Bronstein AM; Furman JM; Goadsby PJ; Neuhauser H; Radtke A; Versino M (2011). "Response to: Migraine and Vertigo: A Marriage of Convenience?". Headache. 51 (2): 308–309. doi:10.1111/j.1526-4610.2010.01834.x. PMID 21284614.
  3. Lempert T, Neuhauser H (August 2005). "Migrainous vertigo". Neurol Clin. 23 (3): 715–30, vi. doi:10.1016/j.ncl.2005.01.003. PMID 16026673.
  4. Neuhauser H, Lempert T (February 2004). "Vertigo and dizziness related to migraine: a diagnostic challenge". Cephalalgia. 24 (2): 83–91. doi:10.1111/j.1468-2982.2004.00662.x. PMID 14728703.
  5. Lempert T, Neuhauser H (March 2009). "Epidemiology of vertigo, migraine and vestibular migraine". J. Neurol. 256 (3): 333–8. doi:10.1007/s00415-009-0149-2. PMID 19225823.
  6. Cal R, Bahmad Jr F (2008). "Migraine associated with auditory-vestibular dysfunction" (PDF). Braz J Otorhinolaryngol. 74 (4): 606–12. doi:10.1016/S1808-8694(15)30611-X. PMID 18852990.
  7. Felisati G, Pipolo C, Portaleone S (June 2010). "Migraine and vertigo: two diseases with the same pathogenesis?". Neurol. Sci. 31 Suppl 1: S107–9. doi:10.1007/s10072-010-0299-0. PMID 20464597.
  8. Benson AG, Chark DW, Djalilian HR, Robbins WK, Battista RA (November 20, 2008). "Migraine-associated vertigo". WebMd. Retrieved October 27, 2010.
  9. Fotuhi M, Glaun B, Quan SY, Sofare T (May 2009). "Vestibular migraine: a critical review of treatment trials". J. Neurol. 256 (5): 711–6. doi:10.1007/s00415-009-5050-5. PMID 19252785.
  10. Maldonado Fernández, Miguel; Birdi, Jasminder S.; Irving, Greg J.; Murdin, Louisa; Kivekäs, Ilkka; Strupp, Michael (2015-06-21). "Pharmacological agents for the prevention of vestibular migraine". The Cochrane Database of Systematic Reviews (6): CD010600. doi:10.1002/14651858.CD010600.pub2. ISSN 1469-493X. PMC 6494480. PMID 26093662.
  11. Salhofer, S; Lieba-Samal D; Freydl E; Bartl S; Wiest G; Wöber C (2010). "Migraine and vertigo--a prospective diary study". Cephalalgia. 30 (7): 821–828. doi:10.1177/0333102409360676. PMID 20647173.
Classification
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