Neurotologic findings in basilar migraine

Eye Movement Abnormalities During Different Periods in Patients with Vestibular Migraine

Purpose

The aim of this study was to assess abnormal eye movement signs during different periods, namely, ictal periods and symptom-free intervals, in patients with vestibular migraine.

Patients and Methods

We assessed oculomotor signs using videonystagmography in 90 patients with VM (40 during ictal periods and 50 during symptom-free intervals) according to validated diagnostic criteria.

Results

Abnormal saccades, smooth pursuit and optokinetic test results; spontaneous nystagmus; and positional nystagmus were all observed in vestibular migraine patients, and there was no significant difference between different periods. Positional nystagmus was the most common in both the ictal and asymptomatic periods (60% and 36%, respectively). Positional nystagmus was induced in a variety of positions during both periods, and the slow-phase velocity ranged from <2 to 10°/s. The duration of positional nystagmus was over 60s in most cases. Overall, central oculomotor dysfunctions occurred in 27.5% of patients during VM attacks and 4% of patients during symptom-free intervals; this difference was statistically significant (p = 0.002).

Conclusion

In patients with VM, abnormal oculomotor signs can be found during both vertigo attacks and asymptomatic intervals. Positional nystagmus is the most common of these abnormalities and can be induced in different positions. The amplitude of these patients' positional nystagmus tends to be low, and the duration tends to be long. Observing changes in eye movements by videonystagmography may be helpful in the diagnosis of VM.

Migraine-Associated Otalgia: An Underappreciated Entity

Background and Objectives

Otalgia can be primary/otogenic or secondary as a referred pain from another site, which can be difficult to establish owing to various causes and the complex innervation of the ear. In our center, we observed a large group of patients with unexplained otalgia that had a higher prevalence of migraine. We hypothesized that migraine may cause secondary otalgia. This study then aimed to determine the prevalence of migraine-associated otalgia and evaluate the efficacy of migraine treatment.

Subjects and Methods

This 2-year retrospective study was conducted at a busy otology clinic. Patients were identified using diagnostic codes corresponding to otalgia. The prevalence of migraine-associated otalgia was determined, and the efficacy of migraine treatment was evaluated in these patients. The interventions included prophylactic and abortive migraine treatments. Statistical analysis was conducted to compare between the pre- and post-treatment symptoms.

Results

A total of 208 patients with otalgia were identified. Sixty-four out of ninety patients with unexplained otalgia met the criteria for migraine; of them, 30 patients had an adequate follow-up and were thus included in the evaluation of treatment efficacy. Otalgia improved in 87% of the patients who received migraine treatment. After treatment, the mean pain score and headache frequency significantly decreased from 7 to 2 and from 27 to 9 days per month, respectively (p<0.001).

Conclusions

Migraine should be considered as a source of secondary otalgia, and patients should receive treatment as they often respond to migraine treatment.

Normative data for ages 18-45 for ocular motor and vestibular testing using eye tracking

OBJECTIVE

Eye tracking technology has been employed in assessing ocular motor and vestibular function following vestibular and neurologic conditions, including traumatic brain injury (TBI). Assessments include tests that provide visual and motion (rotation) stimuli while recording horizontal, vertical, and torsional eye movements. While some of these tests have shown diagnostic promise in previous studies, their use in clinical practice is limited by the lack of normative data. The goal of this study was to construct normative reference ranges to be used when comparing patients' results.

METHODS

Optokinetic response, subjective visual horizontal and vertical, and rotation tests were administered to male and female volunteers, ages 18-45, who were free from neurological, vestibular disorders, or other head injuries. Tests were administered using either a rotatory chair or a portable virtual reality-like goggle equipped with video-oculography.

RESULTS

Reference values for eye movements in response to different patterns of stimuli were analyzed from 290 to 449 participants. Analysis of gender (self-reported) or age when grouped as pediatric (late adolescent; 18-21 years of age) and adult (21-45 years of age) revealed no effects on the test metrics. Data were pooled and presented for each test metric as the 95% reference interval (RI) with 90% confidence intervals (CI) on upper and lower limits of the RI.

CONCLUSIONS

This normative database can serve as a tool to aid in diagnosis, treatment, and/or rehabilitation protocols for vestibular and neurological conditions, including mild TBI (mTBI). This database has been cleared by the FDA for use in clinical practice (K192186).

LEVEL OF EVIDENCE

2b.

"Sound attacks": a case report of migraine with hearing aura

IntroductionMigraine with aura is less frequent than the subtype form without aura. Normally, auras are typically manifested visual symptoms, but it is possible to have an auditory and olfactory complains as aura symptomatology.Case reportAn 8-year-old boy with family cases of migraine, complained of auditory hallucination episodes, since he was 5 years-old, with a duration of 10 to 20 minutes, followed by cure with intense photophobia and nausea. He called these episodes as "sound attacks". The frequency of the crises ranges from 4 to 5 episodes per month, with the maximum of 11 episodes in one month.Neurological examination was normal. He performed angio-MRI of skull and EEG, without any changes. Treatment was initiated with 250 mg sodium divalproate at night with reduction of events, already in the first month, for 2 to 3 episodes per month. The medication was adjusted for 500 mg of sodium divalproate with a good result, not presenting new episodes in the last 2 months.ConclusionWe report a case of migraine crises preceded by auditory aura, in a boy of 8 years. This is a rare and extremely interesting presentation of migraine, with great improvement after the prophylactic treatment.

Migraine understood as a sensory threshold disease

Migraine encompasses a broader spectrum of sensory symptoms than just headache. These "other" symptoms, eg, sensory phobias, cognitive and mood changes, allodynia, and many others indicate an altered sensitivity to sensory input which can be measured, in principle, by quantifying sensory threshold changes longitudinally over time. Photophobia, for example, can be quantified by investigating the discomfort thresholds towards the luminance of light. The aim of this review is to look into how thresholds change in patients with migraine. We performed a PubMed search up to June 2018 targeting all peer-reviewed articles evaluating the changes in threshold, sensory phobia, or sensitivity in patients with migraine. Migraineurs, in general, exhibit lower sensory thresholds compared with healthy controls. These threshold changes seem to follow the different phases during a migraine cycle. In general, thresholds reach a nadir when the headache starts (the ictal phase), rise after the headache ends, and then gradually descend towards the next attack. The sensory modality of measurement-mechanical, thermal, or nociceptive-and the location of measurement-trigeminal vs somatic dermatome-also influence the sensory threshold. Functional imaging studies provide evidence that the hypothalamo-thalamo-brainstem network may be the driving force behind the periodic threshold changes. In summary, there is evidence in the literature that migraine could be understood as a periodic sensory dysregulation originating from the brain. Nevertheless, the interstudy discrepancy is still high due to different study designs and a lack of focus on distinct migraine phases. Further well-designed and harmonized studies with an emphasis on the cyclic changes still need to be conducted.

Migraine and episodic Vertigo: a cohort survey study of their relationship

Background and aim

Migraine headache and vestibular-type vertigo co-occur in the general population about three times more often than expected by chance. Attacks of episodic vertigo (eV) are currently not recognized as migraine equivalents or variants in the International Classification of Headache Disorders, 3rd edition (ICHD III). No strong data exist about the prevalence of eV during the phases of a migraine attack. The aim of this study is to analyze the timing association between migraine-related episodic vertigo and the phases of migraine.

Methods

The “Migraine and Neck Pain Study” gathered data from nearly 500 adult participants in a questionnaire-based survey. In this prospective, follow-up study we re-analyzed patients with episodic migraine with and without aura who experienced eV anytime around their migraine attacks. For this we defined 3 different time periods.

Results

146/487 (30%) reported eV anytime during the migraine attack; 79/487 (16%) that noticed eV with the start of the headache, 51/487 (10%) within 2 h before the headache and 16/487 (3%) experienced eV 2–48 h before the headache, as a premonitory symptom. 130/487 (26.7%) of our patients can be diagnosed with vestibular or probable vestibular migraine supporting the clinical association of migraine and vertigo.

Conclusions

Our results seem to further support the concept that vertigo in migraine is best thought of as an integral manifestation of migraine, rather than a prodromal or aura symptom.

Painful Stimulation of the Temple During Optokinetic Stimulation Triggers Migraine-Like Attacks in Migraine Sufferers

To determine whether motion sickness induced by optokinetic stimulation would trigger migraine-like attacks, 27 migraine sufferers and 23 controls attended the laboratory up to three times at intervals of at least 3 weeks. On one occasion subjects experienced up to 15 min of optokinetic stimulation, followed by three 30-s applications of ice to the temple at 4-min intervals. On another occasion, the ice applications preceded and accompanied optokinetic stimulation. On a third occasion, one hand was immersed in ice water for 30 s, three times at 4-min intervals before and during optokinetic stimulation. Subjects recorded headache activity in a diary over the course of the study. None of the controls experienced a migraine-like attack at any stage of the experiment. In migraine sufferers, the incidence of migraine-like attacks was greater than the expected daily incidence of 8% after sessions that involved painful stimulation of the temple during or after optokinetic stimulation (44% and 28% of the group, respectively) ( P < 0.001). In contrast, migraine-like attacks developed in only 13% of migraine sufferers after the session that involved immersing the hand in ice water during optokinetic stimulation (not significant). The development of nausea and headache during optokinetic stimulation increased the likelihood of migraine-like attacks afterwards. These findings indicate that motion sickness and head pain increase susceptibility to migrainous attacks in migraine sufferers, and suggest that the symptoms of migraine build upon each other in a vicious circle. Thus, targeting multiple symptoms should be more effective than targeting individual symptoms, both for preventing and treating attacks of migraine.

Characteristics of patients with unilateral and bilateral Ménière's disease

OBJECTIVE

To evaluate epidemiologic differences between patients with unilateral and bilateral Ménière's disease (MD). To evaluate these differences for insights into the possible causes of bilateral MD.

BACKGROUND

The diagnosis of MD is based on clinical criteria, and its cause is unknown. Differences in characteristics of patients with unilateral and bilateral MD have been noted, but these studies' diagnostic criteria have been variable. To delineate findings that might have implications as to the cause of MD, we have studied rigidly selected patient populations with unilateral and bilateral MD STUDY DESIGN: Prospective cohort.

MATERIALS AND METHODS

Patients with a potential diagnosis of MD underwent extensive evaluations (audiometric, radiologic, and immunologic), and only patients with idiopathic MD were included in this study. Bilaterality of disease was based on clinical and audiometric criteria. Variables identified as part of the evaluation were subjected to statistical analyses to determine if significant differences existed in the characteristics of patients in the unilateral and bilateral groups

RESULTS

Patients with bilateral disease presented at a significantly younger age and had a significantly higher incidence of a personal history of migraines and a family history of MD. None of the other identified variables were found to be significantly different.

CONCLUSION

Patients with bilateral MD have a higher incidence of migraines and of a family history of MD. Implications as to disease pathogenesis are discussed.

Assessment of cochlear and auditory pathways in patients with migraine

PURPOSE

In this study, we aimed to determine the function of the cochlea and peripheral and central auditory pathways with migraine.

MATERIALS AND METHODS

Fifty-eight patients with migraine and 40 healthy subjects were assessed using routine diagnostic audiometry along with transient evoked otoacoustic emissions (TOAEs), distortion product otoacoustic emissions (DPOAEs), and auditory brainstem response (ABR) at high and low repetition rate frequencies.

RESULTS

Nearly two thirds of patients with migraine had one or more abnormalities in electrophysiological testing. Compared with control subjects, patients reported significant lowering of TOAEs amplitude at frequencies of 1 kHz (right: P = .0003; left: P = .002), 3 kHz (right: P = .025), and 4 kHz (right: P = .019); prolonged wave III latency (right: P = .009); and I-V interpeak latency (IPL) (left: P = .024) at high repetition rate frequencies. Significant correlations were identified between age, duration of illness and frequency of migraine and TOAEs total response and at amplitude of 4 kHz, amplitudes of DPOAEs at 1, 1.5, 2, 3, and 5 kHz and I, III and wave latencies and I-V IPL of ABR at high rate frequencies.

CONCLUSIONS

These data suggest that subclinical changes in cochlear function and auditory pathways are associated with chronic migraine. It is possible that migraine could be accompanied by compromise of blood supply of auditory system.

Vestibular migraine--validity of clinical diagnostic criteria

BACKGROUND

Clinical recognition of vestibular migraine (VM) is still hampered by the lack of consensus diagnostic criteria. The aim of this study is a long-term evaluation of clinical criteria for definite (dVM) and probable (pVM) vestibular migraine.

METHODS

We re-assessed 75 patients (67 women, age 24-76 years) with dVM (n=47) or pVM (n=28) according to previously published criteria after a mean follow-up of 8.75±1.3 years. Assessment included a comprehensive neurotological clinical examination, pure tone audiometry and caloric testing.

RESULTS

dVM was confirmed in 40 of 47 patients with a prior diagnosis of dVM (85%). Fourteen of 28 patients initially classified as pVM met criteria for dVM (50%), nine for pVM (32%). Six additional patients with dVM and two with pVM had developed mild sensorineural hearing loss, formally fulfilling criteria for bilateral Menière's disease (MD), but had clinical features atypical of MD. Seven of these also met criteria for dVM at follow-up. The initial diagnosis was completely revised for four patients.

CONCLUSION

Although VM diagnosis lacks a gold standard for evaluation of diagnostic criteria, repeated comprehensive neurotological evaluation after a long follow-up period indicates not only high reliability but also high validity of presented clinical criteria (positive predictive value 85%). Half of patients with pVM evolve to meet criteria for dVM. However, in a subgroup of VM patients with hearing loss, criteria for dVM and MD are not sufficiently discriminative.

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.

Potential solutions to several vestibular challenges facing clinicians

Among other problems, patients with vestibular problems suffer imbalance, spatial disorientation, and blurred vision. These problems lead to varying degrees of disability and can be debilitating. Unfortunately, a large number of patients with vestibular complaints cannot be diagnosed with the clinical tests available today. Nor do we have treatments for all patients that we can diagnose. These clinical problems provide challenges to and opportunities for the field of vestibular research. In this paper, we discuss some new diagnostic and treatment options that could become available for tomorrow's patients. As a new diagnostic, we have begun measuring patient's perceptual direction-detection thresholds. Preliminary results appear encouraging; patients diagnosed with bilateral loss have yaw rotation thresholds almost ten times greater than normals, while patients diagnosed with migraine associated vertigo have roll tilt thresholds well below normal at 0.1 Hz. As a new treatment, we have performed animal studies looking at responses evoked by electrical stimulation provided by a vestibular prosthesis. Results measuring the VOR demonstrate promise and preliminary studies of balance and perception are also encouraging. While electrical stimulation is a standard means of stimulation, optical stimulation is also being investigated as a way to improve prosthetic stimulation specificity.

Locus for familial migrainous vertigo disease maps to chromosome 5q35

OBJECTIVES

Migrainous vertigo (episodic vertigo associated with migraine) is sometimes inherited as an autosomal dominant trait. However, neither disease genes nor loci that might be responsible have been reported. We sought to map the genetic locus for familial migrainous vertigo in a 4-generation family and to define the progression of disease in this family.

METHODS

We studied 23 members in a family in whom migrainous vertigo was inherited as an autosomal dominant trait. Clinical information obtained included case histories and results of otolaryngological, neurologic, audiometric, and imaging evaluations. Genome-wide linkage analysis was performed with Affymetrix Genechip Human Mapping 10K microarrays. Genotyping of family members' DNA with microsatellite markers was used to further assess candidate loci identified from the whole-genome scan.

RESULTS

Of 23 family members, 10 suffered from migrainous vertigo beginning after 35 years of age. Migraine headaches usually preceded the onset of vertigo by 15 to 20 years. Longitudinal audiometric studies over 12 years showed stable, high-frequency sensorineural hearing loss consistent with presbycusis. Low-frequency or fluctuating hearing loss was not observed. The results of vestibular testing and imaging studies were unremarkable. Genetic analysis defined a 12.0 MB interval on chromosome 5q35 between loci rs244895 and D5S2073 that contained the disease gene (logarithm of odds score, 4.21).

CONCLUSIONS

We report the first locus for familial migrainous vertigo, which mapped to 5q35.

Migraine associated with auditory-vestibular dysfunction

The association between hearing and balance disorders with migraine is known since the times of the ancient Greeks, when Aretaeus from Cappadocia in 131 B.C, made an accurate and detailed description of this occurrence during a migraine episode. We present a broad review of migraine neurotological manifestations, using the most recent publications associated with epidemiology, clinical presentation, pathophysiology, diagnostic methods and treatment for this syndrome.

AIM

To describe the clinical entity: "Migraine associated with auditory-vestibular dysfunction" in order to help otorhinolaryngologists and neurologists in the diagnosis and management of such disorder.

FINAL REMARKS

There is a strong association between neurotological symptoms and migraine, and the auditory-vestibular dysfunction-associated migraine is the most common cause of spontaneous episodic vertigo (non-positional). Symptoms may vary broadly among patients, making it a diagnostic challenge to the otorhinolaryngologist. This entity usually presents with positional or spontaneous vertigo spells, lasting for seconds or days, associated with migraine symptoms. A better understanding of the relationship between central vestibular mechanisms and migraine mechanisms, besides the discovery of ionic channel disorders in some cases of migraine, ataxia and vertigo, may lead to a better understanding of migraine pathophysiology associated with audio-vestibular disorder.

Enxaqueca associada a disfunção auditivo-vestibular

A associação de distúrbios da audição e equilíbrio com enxaqueca é reconhecida desde a Grécia antiga quando Aretaeus da Capadócia em 131 a.C., fez uma descrição precisa e com detalhes desta ocorrência durante uma crise de enxaqueca. Uma revisão ampla das manifestações otoneurológicas da enxaqueca é apresentada, usando as mais recentes publicações com respeito à epidemiologia, apresentação clínica, fisiopatologia, métodos diagnósticos e manejo desta síndrome. OBJETIVO: Descrever a entidade clínica "Enxaqueca associada a Disfunção Auditivo-vestibular" no intuito de ajudar médicos otorrinolaringologistas e neurologistas no diagnóstico e no manejo clínico dessa doença. COMENTÁRIOS FINAIS: Uma forte associação existe entre sintomas otoneurológicos e enxaqueca, sendo a enxaqueca associada a disfunção auditivo-vestibular a causa mais comum de vertigem episódica espontânea (não-posicional). Os sintomas podem variar bastante entre pacientes tornando um desafio diagnóstico para o otorrinolaringologista. Esta entidade geralmente se apresenta com ataques de vertigem espontâneos ou posicionais, durando de segundos a dias com sintomas de enxaqueca associados. Uma melhor elucidação da ligação entre os mecanismos vestibulares centrais e os mecanismos da enxaqueca em si, além da descoberta de defeitos em canais iônicos em algumas causas de enxaqueca, ataxia e vertigem, podem levar a um entendimento maior da fisiopatologia da enxaqueca associada a disfunção auditivo-vestibular.

Subclinical Dysfunction of Cochlea and Cochlear Efferents in Migraine: An Otoacoustic Emission Study

Otoacoustic emission (OAE) testing enables us to identify the cochlear component of a hearing disorder and to monitor objectively minute changes in cochlear status undetectable by other audiological methods. Contralateral sound-induced suppression is mediated by medial superior olivary complex efferents which induce hyperpolarization counteracting the amplifying effects of outer hair cell (OHC) activity. The aim of this study was to assess functions of cochlea and its efferents in migraine using OAE testing and contralateral suppression of transiently evoked OAEs (TEOAE). Fifty-three migraineurs (106 ears) and 41 healthy subjects (82 ears) were included and pure tone audiometry (PTA), speech discrimination scores (SDS), distortion product OAE (DPOAE), TEOAE and contralateral suppression of TEOAEs were tested. PTA and SDS of migraineurs and controls were not different ( P > 0.05). DPOAEs were tested between 1 and 6 kHz and a significant difference was detected only at 5 kHz frequency, where DPOAE amplitudes in migraine with aura (MA) were lower than in controls ( P < 0.03). The mean amplitudes of TEOAEs were statistically insignificant between controls and migraine groups. Contralateral sound stimulus induced significant decrease in amplitudes of TEOAE ( P = 0.005) in controls. In patients with migraine without aura and MA, mean amplitudes of TEOAEs were not suppressed by contralateral sound stimulus ( P > 0.05). As PTA, SDS and DPOAE tests demonstrate normal functioning of inner ear between 1 and 4 kHz, absence of suppression of the TEOAEs by contralateral sound stimulation indicates the presence of dysfunction either in the medial olivocochlear complex in the brainstem or at the synaptic transmission between olivocochlear efferents and OHCs in the cochlea. Disruption in the contralateral suppression may be one of the mechanisms predisposing to the phonophobia symptom associated with migraine headache.

Migraine-related vertigo: diagnosis and treatment

A comprehensive review of the neurotologic manifestations of migraine is presented, focusing on the most recent publications regarding the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of migraine-related vertigo (MV). A strong association exists between vertigo and migraine, with MV being the most common cause of spontaneous (nonpositional) episodic vertigo. Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. Operational diagnostic criteria have been proposed but are not included in the most recent International Headache Society classification of migraine. Better elucidation of the neurologic linkages between the central vestibular pathways and migraine-related pathways and the discovery of ion channel defects underlying some causes of familial migraine, ataxia, and vertigo have furthered the understanding of MV pathophysiology. Treatment of MV currently parallels that of migraine headache, as proper studies of optimal MV management are just beginning.

Auditory brainstem response in pediatric migraine: during the attack and asymptomatic period

OBJECTIVE

The aim of this study was to evaluate the hearing parameters of children with migraine during ictal and interictal period.

METHOD

16 pediatric patients with migraine and normal otolaryngologic examination were evaluated. Hearing parameters were assessed with auditory brainstem response (ABR) testing between and during the migraine attacks. Binaural absolute latencies of waves I, III and V, interpeak latencies I-III, III-V and I-V of ABR in response to 80 dB nHL clicks were calculated. Initial findings were compared with those of 20 healthy volunteers.

RESULTS

Peak latencies of wave V and interpeak latencies of I-V were prolonged during the attack in migraineurs on the left. The side of latency elongation was not affected by the side of headache. When these parameters were separately compared for gender, they were prolonged in boys during the attack in migraineurs; however in girls, while there was statistically significant difference at interpeak latencies of I-V, no significant difference was noted at peak latencies of wave V.

CONCLUSIONS

ABR waves did not exceed clinical norms in migraine patients in headache-free period. But, important effects on sensorineural hearing parameters were detected during the attack. Our results indicated a transient impairment of the auditory brainstem function during the headache in pediatric migraine patients.

Migraine-related vertigo: Diagnosis and treatment

A comprehensive review of the neurotologic manifestations of migraine is presented, focusing on the most recent publications regarding the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of migraine-related vertigo (MV). A strong association exists between vertigo and migraine, with MV being the most common cause of spontaneous (nonpositional) episodic vertigo. Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. Operational diagnostic criteria have been proposed but are not included in the most recent International Headache Society classification of migraine. Better elucidation of the neurologic linkages between the central vestibular pathways and migraine-related pathways and the discovery of ion channel defects underlying some causes of familial migraine, ataxia, and vertigo have furthered the understanding of MV pathophysiology. Treatment of MV currently parallels that of migraine headache, as proper studies of optimal MV management are just beginning.

Vestibulo‐Ocular Reflex Abnormalities in Patients With Migraine

OBJECTIVE

To investigate the high-frequency vestibulo-ocular reflex (VOR) in patients with migraine, with and without dizziness and aura.

BACKGROUND

Migraine is a common cause of dizziness. Although many vestibular testing abnormalities have been documented in migraine patients, high-frequency VOR abnormalities have not been reported.

METHODS

Thirty-nine consecutive patients with migraine were studied with the vestibular autorotation test (VAT). The patients were subclassified as having migraine headache only, migraine with visual aura, migraine with dizziness, or migraine with visual aura and dizziness.

RESULTS

Only a high vertical phase in the 4 to 5 Hz range was correlated with migraine (correlation coefficients: .356, P=.03). Further analysis revealed that an abnormal 4 to 5 Hz vertical phase result also was positively correlated with migraine with aura and dizziness (correlation coefficients: .392).

CONCLUSION

The results suggest that patients with migraine may have an abnormal vertical VOR at higher head movement frequencies. Migraine patients with visual aura and dizziness are even more likely to have this abnormality.

Oscillucusis and sudden deafness in a migraine patient

Migraine is a complex disease that includes neurologic, gastrointestinal and autonomic symptoms, although headache is most common feature. In a portion of cases headache is preceded by focal neurologic symptoms termed auras. Auditory symptoms only rarely occur as part of an aura. We describe a patient whose 13-year migraine history that included the abnormal perception an oscillation of the intensity of ambient sounds (oscillucusis). During a migraine attack immediately after oscillucusis, the patient developed acute and permanent sudden deafness. Clinical and neurologic examinations revealed only profound hearing loss in her left ear. Audiometric testing confirmed the sensorineural nature of the hearing loss. The clinical aspects and physiopathology of auditory symptoms in this case and in patients with migraine is reviewed.

Motion sickness and migraine: optokinetic stimulation increases scalp tenderness, pain sensitivity in the fingers and photophobia

The aim of this study was to determine whether scalp tenderness and photophobia, two well-recognized symptoms of migraine, develop during the motion sickness induced by optokinetic stimulation. To investigate whether motion sickness has a general influence on pain perception, pain was also assessed in the fingertips. After optokinetic stimulation, nausea increased more and headache persisted longer in 21 migraine sufferers than in 15 non-headache controls. Scalp tenderness increased during optokinetic stimulation in nauseated subjects, and pain in the fingertips increased more and photophobia persisted longer in migraine sufferers than controls. These findings suggest that the disturbance responsible for nausea also sensitizes trigeminal nociceptive neurones or releases inhibitory controls on their discharge. A low nausea threshold and a propensity for sensitization to develop rapidly in nociceptive pathways may increase susceptibility to migraine.

Static stabilometry in patients with migraine and tension-type headache during a headache-free period

The vestibulospinal system was evaluated using a stabilometric method in patients with migraine and episodic tension-type headache during headache-free periods. Migraine patients often complain of dizziness or vertigo during headache attacks and some exhibit these symptoms between attacks. Computerized static stabilometry is a reliable and non-invasive technique to evaluate the equilibrium function in various diseases. The subjects consisted of 21 patients with migraine, 12 patients with episodic tension-type headache and, age- and sex-matched controls. We performed two sets of static stabilometric measurements with eyes open (EO) and eyes closed (EC) for 30 s. The averages of two sessions of the following six stabilometric parameters were used for the analysis: locus length (LNG), environmental area (ENV-AREA), rectangle area (REC-AREA), locus length per second, locus length per environ area (L/E), and root mean square area. Romberg quotients (EC/EO) of these six parameters were also analyzed. The mean values of LNG, ENV-AREA and REC-AREA in the EC session in the migraine group were significantly greater than those in the controls (P < 0.05, Mann-Whitney rank sum test). Romberg quotients of all stabilometric parameters except the L/E in the migraine group were significantly greater than in the controls. Patients with episodic tension-type headache did not show any differences in the stabilometric study from the controls. The present findings suggest that patients with migraine show a significant increase of the body sway during the EC session, which indicates an underlying dysfunction in the vestibulospinal system.

Visual, long-latency auditory and brainstem auditory evoked potentials in migraine: relation to pattern size, stimulus intensity, sound and light discomfort thresholds and pre-attack state

We aimed to estimate primary sensory evoked potential (EP) amplitude, amplitude-intensity functions and habituation in migraine patients compared with healthy control subjects and to investigate the possible relation to check size, sound and light discomfort thresholds, and the time to the next attack. Amplitudes of cortical visual evoked potentials (VEP, check size 8' and 33'), cortical long latency auditory evoked potential (AEP NIP1; 40, 55 and 70 dB SL tones) and brainstem auditory evoked potential (BAEP wave IV-V; 40, 55 and 65 dB SL clicks) were recorded and analysed in a blind and balanced design. The difference between the response to the first and the second half of the stimulus sequence was used as a measure of habituation. Twenty-one migraine patients (16 women and five men, mean age 39.3 years, six with aura, 15 without aura) and 22 sex- and age-matched healthy control subjects were studied (18 women and four men, mean age 39.5 years). Low sound discomfort threshold correlated significantly with low levels of BAEP wave IV-V amplitude habituation (r = -0.30, P = 0.05). VEP an AEP amplitudes, habituation, and amplitude-intensity function (ASF) slopes did not differ between groups when ANOVA main factors were considered. Control group VEP habituation was found for small check stimuli (P = 0.04), while potentiation was observed for medium sized checks (P = 0.02). The eight migraine patients who experienced headache within 24 h after the test tended to have increased BAEP wave IV-V ASF slopes (P = 0.08). This subgroup did also have a significant VEP habituation to small checks (P = 0.04). No correlation was found between different modalities. These results suggest that: (i) VEP habituation/potentiation state and brainstem activatio state may depend on the attack-interval cycle in migraine; (ii) VEP habituation/ potentiation may depend on spatial stimulus frequency; (iii) phonophobia (and possibly photophobia) may depend more on subcortical (brainstem) function than on cortical mechanisms; (iv) low cortical preactivation in migraine could not be confirmed; (v) EP habituation and ASF analysis may reflect sensory modality-specific, not generalized, central nervous system states in migraine and healthy control subjects.

Ocular and optic nerve head ischemic disorders and hearing loss

PURPOSE

To investigate in an exploratory study whether any evidence suggests that ophthalmic ischemic disorders, particularly of the optic nerve head, are associated with hearing loss.

METHODS

We investigated prospectively 583 consecutive patients in eight primary ocular diagnostic groups for associated hearing loss: nonarteritic anterior ischemic optic neuropathy (n = 81), normal-tension glaucoma (n = 36), primary open-angle glaucoma (n = 138), other types of glaucoma (n = 142), ocular arterial occlusive disorders (n = 22), retinal vein occlusion (n = 89), ocular vasculitis (n = 42), and a miscellaneous group (n = 33). The patients and their relatives were questioned in detail for any evidence of hearing loss in the patients.

RESULTS

In the logistic regression model, with presence or absence of hearing loss as the dependent variable and gender, age, and diagnosis as independent variables, gender (P = .003) and age (P<.0001) were found to be significantly associated with hearing loss. No significant association was found with any of the ophthalmic disease groups evaluated in this study. Whenever any significant association with any ophthalmic disease group was seen, this result could be explained by examination of the association between diagnosis and age, which showed a significant (P<.001) association.

CONCLUSIONS

This study showed that there is a significant (P<.001) relationship between hearing loss and aging-the older the population, the higher the incidence of hearing loss-but the study showed that there is no association between hearing loss and ocular and optic nerve head ischemic disorders. The two represent unrelated and independent disorders.

Photophobia and phonophobia in tension-type and cervicogenic headache

Light and sound-induced discomfort and pain thresholds were measured in 26 patients with cervicogenic headache, in 40 patients with tension-type headache, and in 100 headache-free controls. Neither headache group was significantly different as to photophobia and phonophobia, but both were significantly more sensitive to light and sound than controls (p<0.0001), even when patients were tested in the headache-free period (p<0.05). Episodic and chronic tension-type headache had similar photo- and phonophobia thresholds (p> or =0.7). Tension-type headache patients were more photo- and phonophobic during headache than outside attack (p<0.05), but this was not true for cervicogenic headache (p> or =0.56). In cervicogenic headache patients, photophobia (p<0.05) but not phonophobia (p=0.28) was greater on the symptomatic side than on the non-symptomatic side.

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-related vestibulopathy

Migraine has been associated with specific vestibular disorders, including benign paroxysmal vertigo of childhood and benign recurrent vertigo in adults. Migraine may also play a role in chronic nonspecific vestibulopathy. Because scant data exist that describe the clinical findings and vestibular function abnormalities in suspected migraine-related vestibulopathy, we reviewed the history, physical examination, vestibular tests (electronystagmography, rotational chair, posturography), and response to treatment of 100 patients with diagnoses of migraine-related vestibulopathy. Dominant clinical features included chronic movement-associated dysequilibrium, unsteadiness, space and motion discomfort, and occasionally, episodic vertigo as an aura prior to headache, or true vertigo without headache. Common vestibular test abnormalities included a directional preponderance on rotational testing, unilateral reduced caloric responsiveness, and vestibular system dysfunction patterns on posturography. Treatment was usually directed at the underlying migraine condition by identifying and avoiding dietary triggers and prescribing prophylactic anti-migraine medications. Symptomatic relief was also provided using anti-motion sickness medications, vestibular rehabilitation, and pharmacotherapy directed at any associated anxiety or panic disorder.

Visual system dysfunction in migraine: a review of clinical and psychophysical findings

This paper reviews both clinical and experimental literature relating to visual dysfunction in migraine, starting with the eye and progressing via the retina and visual pathways to the visual cortex. Migraine is associated with (i) a pupillary sympathetic hypofunction, and (ii) a cortical hypersensitivity to visual stimuli (perhaps only in migraine with aura), the pathogenesis of which remains to be determined. Various hypotheses are discussed, and it is proposed that the methods of visual psychophysics may represent a useful approach in the future study of cortical hyperexcitability in migraine. Paradoxically, little research has been directed towards understanding (i) the photophobia of migraine attacks, and (ii) how migraine may be triggered by visual stimuli. Research aimed at elucidating the mechanisms of these phenomena may enhance understanding of the pathogenesis of migraine.

Vascular Compression Syndrome of the Vestibular Nerve: A Critical Analysis

The rationale, indications, and surgical results of microvascular decompression for the treatment of vertigo are reviewed, and a critical analysis is made. The syndrome of disabling positional vertigo is discussed. It is concluded that (1) vascular compressive vestibular neuropathy may exist, (2) the current published diagnostic criteria for this disorder are insufficient to firmly establish the diagnosis, and (3) further work delineating this syndrome should be undertaken.