Treatment of Vestibular Migraine: A Systematic Review and Meta-analysis

Short-term effects of lifestyle modification on vestibular migraine

OBJECTIVE

Our primary purpose was evaluation of early benefits of lifestyle modification on symptoms of vestibular migraine. The secondary purpose was to determine if a patient's global sense of coping relates to outcomes with lifestyle modification.

DESIGN

Prospective observational cohort. Participants completed questionnaires related to dizziness handicap, headache disability, and adherence to lifestyle modifications at baseline and weekly over 30 d. Sense of coping was measured pre-intervention.

STUDY SAMPLE

Thirty-eight patients with vestibular migraine diagnosed in tertiary care setting between 2022 and 2023.

RESULTS

Symptoms were better at all four weeks post-intervention than pre-intervention (p < 0.01), with no difference across weeks two through four (p > 0.10) when symptoms were lowest and stable. By week two, 52% and 18.5% of participants had significant improvement in dizziness and headache compared to published critical difference scores, respectively. Sense of coping was inversely correlated with dizziness (R = -0.53, p < 0.00001) and headache (R = -0.64, p < 0.0001).

CONCLUSIONS

Lifestyle modification reduced dizziness and headache in many vestibular migraineurs in the first two weeks following intervention. Improvement in restful sleep was associated with improvement in symptoms. Sense of coping did not predict improvement but was inversely related to symptoms. Lifestyle modification could be considered as sole management or in addition to pharmacological intervention.

Efficacy of Nortriptyline and Migraine Lifestyle Modifications in Vestibular Migraine Management

OBJECTIVE

To evaluate the effectiveness of nortriptyline regimen and migraine dietary/lifestyle modifications on dizziness and stress levels in patients diagnosed with vestibular migraine (VM).

METHODS

A total of 35 patients diagnosed with definite VM based on the International Classification of Headache Disorders were included in this intervention study. Patients self-selected to receive either nortriptyline regimen alone (10-40 mg daily with biweekly escalation) (group A, n = 17) or migraine dietary/lifestyle modifications alone (group B, n = 18). Main outcome measures were dizziness severity and stress level measured by the visual analog scale (VAS).

RESULTS

At 4-week post-treatment, dizziness decreased from 6.0 ± 2.5 to 4.2 ± 3.4 (p = 0.069) in group A and from 8.7 ± 1.5 to 3.6 ± 3.0 (p < 0.001) in group B. VAS for stress changed from 5.5 ± 1.3 to 5.4 ± 2.9 (p = 0.93) and from 6.9 ± 3.2 to 5.0 ± 2.7 (p = 0.025) in groups A and B, respectively. The δ values of the VAS score for dizziness were 1.8 ± 3.7 and 5.1 ± 3.1 and the δ values of the VAS score for stress were 0.06 ± 2.9 and 1.9 ± 3.3 in groups A and B, respectively. Quality of life (QOL) improved in 88% patients in group A and 94% patients in group B.

CONCLUSIONS

Nortriptyline, at a maximum dose of 40 mg, effectively alleviates patient symptoms, while a migraine diet and lifestyle modifications notably reduce vertiginous symptoms and stress levels in VM patients in 4 weeks. Both interventions are equally effective in ameliorating the QOL of patients. The ideal treatment for patients would likely need to include both medication and diet/lifestyle changes.

The role of selective serotonin reuptake inhibitors and tricyclic antidepressants in addressing reduction of Meniere's disease burden: A scoping review

Objective

To assess the effect of selective serotonin reuptake inhibitors (SSRIs) and tricyclic antidepressants (TCAs) in reducing vertigo, tinnitus, and hearing loss among patients with Meniere's disease (MD).

Data Sources

The following databases were utilized in this scoping review: Ovid Medline, PubMed-NCBI, CINAHL, Cochrane Library, Web of Science, and Clinicaltrials.gov.

Method

Studies were identified through the following search phrases: "serotonin specific reuptake inhibitors" OR "tricyclic antidepressants" AND "Meniere's disease." References from included manuscripts were examined for possible inclusion of additional studies.

Results

The literature search yielded 23 results, which were screened by three independent reviewers. Seventeen studies and three duplicates were excluded. An examination of references from the included studies yielded two additional publications. A total of four published studies assessing SSRIs and TCAs among 147 patients with MD were ultimately included. Four studies described significant reductions in vertigo attack frequency among patients treated with either SSRIs or TCAs compared to their pretreatment baseline. Three studies assessed the drugs' effects on hearing, of which none found a significant difference among patients treated with SSRIs or TCAs. One study found a significant decrease in patient-reported tinnitus following treatment with TCAs or SSRIs compared to their pretreatment baseline.

Conclusions

Data exploring SSRIs and TCAs among patients with MD suggests that these medications may reduce the frequency of tinnitus and vertigo, although there was significant heterogeneity in outcome reporting. There remains a need for larger-scale prospective studies that emphasize objective data to evaluate their effectiveness in reducing common MD symptoms.

Vertiginous epilepsy in the pediatric population

Vertiginous epilepsy (VE) is a rare and underrecognized epilepsy subtype in the pediatric population. Vertiginous symptoms are the sole or predominant feature, arise from the vestibular cortex, and seizures are usually brief. The incidence is estimated to be between six and 15 percent of pediatric patients presenting with dizziness. Diagnosis is often delayed for many years following the onset of symptoms, as there are no widely accepted diagnostic criteria. Diagnostic work-up should include a detailed history, physical exam, EEG, and brain imaging with MRI. Vestibular testing is helpful if peripheral vestibulopathy is suspected. Vertiginous epilepsy can have many possible causes, but a large majority are idiopathic or suspected to be genetic. Most patients with vertiginous epilepsy achieve seizure freedom with anti-seizure medications.

Vestibular migraine: an update

PURPOSE OF REVIEW

We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine.

RECENT FINDINGS

Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways.

SUMMARY

Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).

Assessment and management of vestibular migraine within ENT

OBJECTIVE

Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic.

METHOD

Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine.

RESULTS

A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging.

CONCLUSION

This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.

A role of NLRP3 and MMP9 in migraine progression: a systematic review of translational study

Background

Migraines affect one billion individuals globally, with a higher occurrence among young adults and women. A significant survey in the United States indicated that 17.1% of women and 5.6% of men suffer from migraines. This study seeks to investigate the potential connection between NLRP3 and MMP9 in migraine pathology.

Methods

The research involved searching databases such as PubMed, Scopus, Science Direct, Google Scholar, and Proquest, with the search concluding on March 31, 2024. Following PRISMA guidelines, PICO data were collected, focusing exclusively on animal models induced by Nitroglycerine (10 mg/kg), while excluding clinical studies.

Results

The study, originally registered in Prospero Reg. No. CRD42022355893, conducted bias analysis using SYRCLE's RoB tool and evaluated author consensus using GraphPad v9.5.1. Out of 7,359 search results, 22 papers met the inclusion criteria. Inter-rater reliability among reviewers was assessed using Cohen's kappa statistics.

Conclusion

This review summarizes 22 preclinical studies on Nitroglycerin (NTG), NLRP3, MMP9, and related biomarkers in migraine. They reveal that NTG, especially at 10 mg/kg, consistently induces migraine-like symptoms in rodents by activating NLRP3 inflammasome and stimulating proinflammatory molecule production.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, CRD42022355893.

The Efficacy of Vestibular Rehabilitation Therapy for Mild Traumatic Brain Injury: A Systematic Review and Meta-analysis

OBJECTIVE

Mild traumatic brain injury (mTBI) or concussion is a common yet undermanaged and underreported condition. This systematic review and meta-analysis aim to determine the efficacy of vestibular rehabilitation therapy (VRT) as a treatment option for mTBI.

METHOD

This review and meta-analysis was performed following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. It included randomized controlled trials and pre-VRT/post-VRT retrospective chart reviews. Records meeting the inclusion criteria were extracted from the following databases: MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials (CENTRAL).

RESULTS

Eight articles met the inclusion criteria, from which 6 randomized controlled trials were included in the meta-analysis. VRT demonstrated significant improvement in decreasing perceived dizziness at the end of the intervention program as shown by Dizziness Handicap Inventory (DHI) scores (standardized mean difference [SMD] = -0.33, 95% confidence interval [CI]: -0.62 to -0.03, P = .03, I2 = 0%). However, no significant reduction in DHI was evident after 2 months of follow-up (SMD = 0.15, 95% CI: -0.23 to 0.52, P = .44, I2 = 0%). Quantitative analysis also depicted significant reduction in both Vestibular/Ocular Motor Screening (SMD = -0.40, 95% CI: -0.60 to -0.20, P < .0001, I2 = 0%) and Post-Concussion Symptom Scale (SMD= -0.39, 95% CI: -0.71 to -0.07, P = .02, I2 = 0%) following the intervention. Finally, there was no significant difference between intervention groups on Balance Error Scoring System scores (SMD = -31, 95% CI: -0.71 to 0.10, P = .14, I2 = 0%) and return to sport/function (95% CI: 0.32-30.80, P = .32, I2 = 82%).

CONCLUSIONS

Current evidence on the efficacy of VRT for mTBI is limited. This review and analysis provides evidence that supports the role of VRT in improving perceived symptoms following concussion. Although findings from this analysis suggest positive effects of VRT on included outcomes, the low certainty of evidence limits the conclusions drawn from this study. There is still a need for high-quality trials evaluating the benefit of VRT using a standardized approach.PROSPERO registration number: CRD42022342473.

The Role of Motion Sensitivity and Headaches on Vestibular Rehabilitation Outcomes in Pediatric Vestibular Migraines

OBJECTIVE

To determine the utility of the motion sensitivity quotient (MSQ) in diagnosing pediatric vestibular migraine (VM) and to characterize the role of motion sensitivity and headache control on vestibular rehabilitation (VR) outcomes in pediatric VM.

STUDY DESIGN

Retrospective cohort analysis.

SETTING

Pediatric tertiary referral center.

PATIENTS

Children (≤18 years old) with dizziness who completed vestibular testing from January 2016 to August 2022, diagnosed with either VM or another vestibular disorder.

INTERVENTIONS

VR, which included MSQ testing.

MAIN OUTCOME MEASURES

Initial MSQ, number and duration of vestibular physical therapy (PT) sessions, PT goals met, and posttreatment MSQ.

RESULTS

Two hundred fifty-seven patients met study criteria. MSQ was not a reliable diagnostic marker in pediatric VM as there was no difference in initial MSQ between VM and non-VM patients (9.4 vs. 7.8 in non-VM, p = 0.014). Both VM (n = 116) and non-VM (n = 141) patients demonstrated significant improvement in MSQ after VR (p = 0.004). However, VM patients tended to be less likely to meet at least one PT goal (60 vs. 77% in non-VM, p = 0.016, d = 0.37), although not significant. VM patients with more frequent headaches had significantly higher initial MSQ (p = 0.008). VM patients with more frequent headaches or higher initial MSQ tended to require increased number and longer duration of VR (small/medium effect size although not statistically significant after Bonferroni correction).

CONCLUSION

VR is an effective treatment for both VM and non-VM pediatric patients. VM patients, especially those with severe motion sensitivity or poorly controlled headaches, may be less responsive to VR and may require increased frequency and duration of VR. Our findings propose the importance of counseling pediatric patients with severe motion sensitivity or uncontrolled migraines regarding realistic expectations of their VR course.

Vestibular Migraine Pathophysiology and Treatment: a Narrative Review

PURPOSE OF REVIEW

To review the diagnosis of vestibular migraine (VM) and update the clinician on the most recent developments in our understanding of its pathophysiology and treatment.

RECENT FINDINGS

Functional imaging studies have identified multiple regions of the brain with abnormal activity and connectivity in VM. There is evidence of abnormal sensory processing and integration in VM patients. Calcitonin gene-related peptide (CGRP) has also been found to play a role in trigeminal and vestibular nucleus pathways. Research into treatment modalities has identified several neuromodulation devices that may be effective in VM. There are a growing number of evidence-based preventive options for VM, including medications that target CGRP. VM is best understood as a sensory processing disorder. CGRP appears to play a role, and further research is needed to fully understand its effects. Treatment options are expanding, but there is still a need for more randomly controlled trials in this area.

Does Catastrophizing Predict Response to Treatment in Patients With Vestibular Disorders? A Prospective Cohort Study

OBJECTIVE

Determine levels of catastrophizing in patients with vestibular disorders and prospectively evaluate their relationship with patient-reported outcome measures.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary care neurotology vestibular disorders clinic.

PATIENTS

Adult patients with various vestibular disorders.

INTERVENTIONS

Patients were given the Dizziness Handicap Inventory (DHI) and the Dizziness Catastrophizing Scale (DCS) at a baseline visit and follow-up visit after treatment.

MAIN OUTCOME MEASURES

Correlation studies were used to determine the relationships between DHI and DCS. Multivariable linear regression was performed to determine the relationship between DCS and DHI change with treatment, accounting for demographic variables.

RESULTS

Forty-six subjects completed both the DHI and the DCS before and after treatment. Patients with higher baseline DCS scores had higher baseline DHI scores ( p < 0.001). There was a significant improvement in both DHI score ( p < 0.001) and DCS ( p < 0.001) at follow-up. Patients who had reduction in DCS scores during were more likely to show reduction in DHI scores ( p < 0.001). A subset of patients had a mindfulness-based stress reduction program included in their treatment. These patients had a greater reduction in both DCS and DHI scores at follow-up compared with those who received other treatments.

CONCLUSIONS

Catastrophizing is associated with higher pretreatment DHI scores and worse treatment outcomes. Addressing dizziness catastrophizing may help improve vestibular outcomes.

Recent Developments in Vestibular Migraine: A Narrative Review

PURPOSE

The aim of this study was to review current literature regarding the epidemiology of vestibular migraine (VM), patient presentation, pathogenesis, and treatment.

RECENT FINDINGS

VM is becoming an increasingly recognized condition in the United States, currently affecting 2.7% of people. Patients may experience vestibular symptoms, such as vertigo and imbalance, with or without other migrainous symptoms. Recent evidence has also shown that patients with VM are at higher risk for cochlear dysfunction, such as sudden deafness, sensorineural hearing loss, and tinnitus. The heritability and genetics are not well understood, and the pathogenesis may involve calcitonin gene-related peptide, which is also implicated in migraine headaches. A disease-specific patient reported outcome measure, the Vestibular Migraine Patient Assessment Tool and Handicap Inventory, was recently developed and validated. A limited number of controlled trials have assessed various therapies for VM, including triptans and beta-blockers. More data are needed to understand whether or not currently available migraine treatments are effective for VM.

SUMMARY

VM is a common etiology of vertigo and dizziness, presenting with a characteristic spectrum of symptoms. Early data suggest that migraine treatments may be helpful in some cases.

Spinning Through History: Evolution of the Concept of Vestibular Migraine

Vestibular migraine represents a growing public health problem, imposing enormous societal burdens in the form of patient suffering, loss of productivity, and direct healthcare costs. This raises the question of how we developed our ideas about vestibular migraine and how these ideas shape how we treat it. This review walks through the history of how our conceptualization of migraine and vestibular symptoms evolved, starting with clinical observations in ancient times, inclusion under the umbrella of Meniere's disease, and then separation from Meniere's disease with its own identity. Tradition, clinical observations, and diagnostic criteria developed by professional societies have played prominent roles in building our current concept of vestibular migraine. A review of the ideas that have shaped our current conception of vestibular migraine may help us to see which ones have stood the test of time and which ones should continue to evolve. As in other disciplines, we study history in medicine to be inspired, warned, and sometimes, to be freed.

Utility of Inter-Frequency Amplitude Ratio of Vestibular-Evoked Myogenic Potentials in Identifying Meniere's Disease: A Systematic Review and Meta-Analysis

OBJECTIVES

A recently devised parameter of vestibular-evoked myogenic potential (VEMP) based on the principles of frequency tuning is the inter-frequency amplitude ratio (IFAR). It refers to the ratio of the amplitude of 1000 Hz tone burst evoked VEMP to 500 Hz evoked tone burst. A pathology like Meniere's disease changes the frequency response and alters the frequency tuning of the otolith organs. Because IFAR is based on the principle of frequency tuning of VEMP, it is likely to help identify Meniere's disease. Few studies in the last decade have investigated the utility of IFAR in identifying Meniere's disease. However, a systematic review and a meta-analysis on IFAR in Meniere's disease are lacking. The present study investigates whether the IFAR of VEMP helps identify Meniere's disease and differentiates it from healthy ears and other vestibular pathologies.

DESIGN

The present study is a systematic review and a meta-analysis. The studies investigating the IFAR of cervical and ocular VEMPs in Meniere's disease, healthy controls, and other vestibular pathologies were searched across research databases such as PubMed, Science Direct, and Scopus. The search strategy was developed using the PICO (population, intervention, comparison, and outcomes) format, and Medical Subject Headings (MeSH) terms and Boolean operators were employed. The systematic review was performed using the Rayyan software, whereas the Review Manager software was used to carry out the meta-analysis. A total of 16,605 articles were retrieved from the databases. After the duplicate removal, 2472 articles remained. These were eliminated using title screening, abstract screening, and full-length inspections. A total of nine articles were found eligible for quality assessment and meta-analysis, and the New Castle-Ottawa Scale was used for quality assessment. After the data extraction, 24 six articles were found to have the desired data format for the meta-analysis.

RESULTS

The results showed significantly higher IFAR in the affected ears of individuals in the Meniere's disease group than in the control group's unaffected ears. There was no significant difference between the unaffected ears of individuals in the Meniere's disease group and the ears of the control group. The only study on Meniere's disease and benign paroxysmal positional vertigo found significantly larger ocular VEMP IFAR in ears with Meniere's disease than in benign paroxysmal positional vertigo.

CONCLUSIONS

This systematic review and meta-analysis found IFAR efficient in differentiating Meniere's disease from healthy controls. We also found an enhanced IFAR as a potential marker for Meniere's disease. However, more investigations are needed to confirm the utility of an enhanced IFAR value in the exclusive identification of Meniere's disease.

A systematic review and meta-analysis of prophylactic medication of vestibular migraine

OBJECTIVE

Vestibular migraine is in the process of recognition as an individual clinical entity. At present, no guidelines exist for its management. This study aimed to conduct a systematic review and meta-analysis to determine the effectiveness of available prophylactic medication.

METHOD

A literature search was performed using PubMed, Ovid and Embase databases. Qualitative and quantitative analysis were performed as well as risk of bias analysis. Meta-analysis for the mean differences for pre- and post-treatment impact based on Dizziness Handicap Inventory and Vertigo Symptom Scale were performed. Proportionate transformation meta-analysis for the successful event rate based on complete symptoms control was explored.

RESULTS

Thirteen publications were identified: 3 were randomised, controlled trials and 10 were non-randomised, controlled trials. Propranolol and venlafaxine improved the Vertigo Symptom Scale score by -13.31 points and -4.16 points, respectively, and the Dizziness Handicap Inventory score by -32.24 and -21.24, respectively. Only propranolol achieved statistically significant impact with 60 per cent of patients achieving complete symptom control.

CONCLUSION

Propranolol should be offered as the first-line treatment for vestibular migraine followed by venlafaxine. Amitriptyline, flunarizine and cinnarizine showed a trend for symptom improvement, but this was not statistically significant.

Manual cervical therapy and vestibular migraine: A case series

Background

Vestibular migraine (VM) is a relatively new diagnostic entity with incomplete knowledge regarding pathophysiological mechanisms and therapeutic guidelines. By reporting the effect of manual cervical therapy (MCT) on people with VM, we suggest a possible role for upper cervical afferents in VM treatment and/or pathogenesis. The objective was to describe the change in clinical presentation and self-reported symptoms of VM corresponding to MCT and followed up to six months.

Methods

A nonrandomised *ABA design was utilised to consecutively and prospectively evaluate selected patients with diagnosed VM. Symptom characteristics (frequency and intensity) were recorded along with standardised patient-reported outcomes (PROs) to document the response to MCT.

Results

Three patients were recruited who met the diagnostic criteria for VM. All three patients demonstrated improvement in both migraine attack and interictal symptom frequency. These improvements mirrored changes in PROs and were sustained over a six-month follow-up period.

Conclusions

The improvement that coincided with the intervention including MCT was rapid, observable and sustained. This suggests that the upper cervical spine could be a therapeutic target in VM and may have implications for future research into the pathogenesis of VM.

Migraine management for the otolaryngologist

Objective

To characterize migraine pathophysiology, presentation, and current treatment strategies, specifically in regard to vestibulocochlear manifestations of migraine.

Methods

Narrative review of available literature.

Results

Migraine disorder can be described as a spectrum of otologic manifestations, with vestibular migraine now recognized with fully-fledged diagnostic criteria. Otologic manifestations are theorized to be due, in part, to trigeminal innervation of the inner ear structures and calcitonin gene-related peptide (CGRP) expression within the labyrinth. Patients can experience vertigo, aural fullness, enhanced tinnitus, and hearing loss without the characteristic migraine headache, leading to under recognition of these symptoms as migraine-related. Meniere's disease, mal de débarquement syndrome, persistent postural perceptual dizziness, and recurrent benign paroxysmal positional vertigo have close associations to migraine and may exist on the migraine spectrum. Migraine treatment consists of two goals: halting acute attacks (abortive therapy) and preventing attacks (prophylactic therapy). Abortive medications include triptans, corticosteroids, anti-histamines, and anti-emetics. Pharmacologic prophylaxis in conjunction with lifestyle modifications can decrease frequency and severity of symptoms and include tricyclic antidepressants, calcium channel blockers, anti-epileptic medications, selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, beta-blockers, gepants, and monoclonal antibodies to CGRP. Promising evidence is emerging regarding the ability of migraine medications to positively treat the various otologic symptoms of migraine.

Conclusion

Migraine disorder manifesting with primarily cochleovestibular symptoms can be challenging to diagnose and manage for practicing clinicians. Patients with various vestibulopathies that are closely related to migraine may benefit from migraine treatment. Lifestyle choices and prophylactic medications are key to satisfactorily preventing acute migrainous attacks and improve function.

Management of Migraine-Associated Vestibulocochlear Disorders

Migraine is a chronic neurological disorder that frequently coexists with different vestibular and cochlear symptoms (sudden hearing loss, tinnitus, otalgia, aural fullness, hyperacusis, dizziness, imbalance, and vertigo) and disorders (recurrent benign positional vertigo, persistent postural perceptual dizziness, mal de debarquement, and Menière's disease). Despite evidence of an epidemiological association and similar pathophysiology between migraine and these vestibulocochlear disorders, patients suffering from migraine-related symptoms are usually underdiagnosed and undertreated. Current migraine treatment options have shown success in treating vestibulocochlear symptoms. Lifestyle and dietary modifications (reducing stress, restful sleep, avoiding migraine dietary triggers, and avoiding starvation and dehydration) and supplements (vitamin B2 and magnesium) offer effective first-line treatments. Treatment with migraine prophylactic medications such as tricyclic antidepressants (e.g., nortriptyline), anticonvulsants (e.g., topiramate), and calcium channel blockers (e.g., verapamil) is implemented when lifestyle and dietary modifications are not sufficient in improving a patient's symptoms. We have included an algorithm that outlines a suggested approach for addressing these symptoms, taking into account our clinical observations. Greater recognition and understanding of migraine and its related vestibular and cochlear symptoms are needed to ensure the appropriate diagnosis and treatment of affected patients.

Interventional Study of Flunarizine Therapy on Symptom Relief and Vestibular Evoked Myogenic Potential Changes in Individuals with Vestibular Migraine

INTRODUCTION

Migraine is the third most common disease in the world with an estimated prevalence of 14.7%. The purpose of this study was to identify the characteristic changes in cervical and ocular vestibular evoked myogenic potential (VEMP) and analyse changes in symptoms and VEMP after flunarizine therapy in patients diagnosed with vestibular migraine (VM).

METHODS

Prospective interventional study was conducted on 31 VM patients. Cervical VEMP (cVEMP) and ocular VEMP (oVEMP) were recorded. Flunarizine (10 mg) was given once daily for two consecutive months. Prophylactic therapy was monitored with a monthly follow-up assessment of their symptoms and VEMP was repeated after 2 months.

RESULTS

Headache was the chief complaint (67.7%). Vertigo was spontaneous and mostly moderate in intensity (93%). cVEMP was absent in 1 patient and oVEMP was absent in 3 patients. Post prophylactic treatment with flunarizine, there was significant reduction in the frequency (p = 0.001) and duration (p = 0.001) of headache and frequency (p = 0.001), duration (p = 0.001), and intensity (p = 0.009) of vertigo. cVEMP and oVEMP showed no significant differences (p > 0.05) between pre- and post-treatment recordings.

CONCLUSION

Treatment with flunarizine helps in considerably reducing the episodes and duration of headache, as well as episodes, duration, and intensity of vertigo.

Non-pharmacological interventions for prophylaxis of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of interventions have been used, or proposed to be used, as prophylaxis for this condition, to help reduce the frequency of the attacks. Many of these interventions include dietary, lifestyle or behavioural changes, rather than medication.  OBJECTIVES: To assess the benefits and harms of non-pharmacological treatments used for prophylaxis of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing dietary modifications, sleep improvement techniques, vitamin and mineral supplements, herbal supplements, talking therapies, mind-body interventions or vestibular rehabilitation with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included three studies in this review with a total of 319 participants. Each study addressed a different comparison and these are outlined below. We did not identify any evidence for the remaining comparisons of interest in this review.   Dietary interventions (probiotics) versus placebo We identified one study with 218 participants (85% female). The use of a probiotic supplement was compared to a placebo and participants were followed up for two years. Some data were reported on the change in vertigo frequency and severity over the duration of the study. However, there were no data regarding improvement of vertigo or serious adverse events. Cognitive behavioural therapy (CBT) versus no intervention One study compared CBT to no treatment in 61 participants (72% female). Participants were followed up for eight weeks. Data were reported on the change in vertigo over the course of the study, but no information was reported on the proportion of people whose vertigo improved, or on the occurrence of serious adverse events.  Vestibular rehabilitation versus no intervention The third study compared the use of vestibular rehabilitation to no treatment in a group of 40 participants (90% female) and participants were followed up for six months. Again, this study reported some data on change in the frequency of vertigo during the study, but no information on the proportion of participants who experienced an improvement in vertigo or the number who experienced serious adverse events.  We are unable to draw meaningful conclusions from the numerical results of these studies, as the data for each comparison of interest come from single, small studies and the certainty of the evidence was low or very low.  AUTHORS' CONCLUSIONS: There is a paucity of evidence for non-pharmacological interventions that may be used for prophylaxis of vestibular migraine. Only a limited number of interventions have been assessed by comparing them to no intervention or a placebo treatment, and the evidence from these studies is all of low or very low certainty. We are therefore unsure whether any of these interventions may be effective at reducing the symptoms of vestibular migraine and we are also unsure whether they have the potential to cause harm.

Pharmacological interventions for prophylaxis of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. These unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used or proposed to be used as prophylaxis for this condition, to help reduce the frequency of the attacks. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar.

OBJECTIVES

To assess the benefits and harms of pharmacological treatments used for prophylaxis of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing beta-blockers, calcium channel blockers, antiepileptics, antidepressants, diuretics, monoclonal antibodies against calcitonin gene-related peptide (or its receptor), botulinum toxin or hormonal modification with either placebo or no treatment. We excluded studies with a cross-over design, unless data from the first phase of the study could be identified.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 3 months, 3 to < 6 months, > 6 to 12 months. We used GRADE to assess the certainty of evidence for each outcome.

MAIN RESULTS

We included three studies with a total of 209 participants. One evaluated beta-blockers and the other two evaluated calcium channel blockers. We did not identify any evidence for the remaining interventions of interest. Beta-blockers versus placebo One study (including 130 participants, 61% female) evaluated the use of 95 mg metoprolol once daily for six months, compared to placebo. The proportion of people who reported improvement in vertigo was not assessed in this study. Some data were reported on the frequency of vertigo attacks at six months and the occurrence of serious adverse effects. However, this is a single, small study and for all outcomes the certainty of evidence was low or very low. We are unable to draw meaningful conclusions from the numerical results. Calcium channel blockers versus no treatment Two studies, which included a total of 79 participants (72% female), assessed the use of 10 mg flunarizine once daily for three months, compared to no intervention. All of the evidence for this comparison was of very low certainty. Most of our outcomes were only reported by a single study, therefore we were unable to conduct any meta-analysis. Some data were reported on improvement in vertigo and change in vertigo, but no information was available regarding serious adverse events. We are unable to draw meaningful conclusions from the numerical results, as these data come from single, small studies and the certainty of the evidence was very low.

AUTHORS CONCLUSIONS

There is very limited evidence from placebo-controlled randomised trials regarding the efficacy and potential harms of pharmacological interventions for prophylaxis of vestibular migraine. We only identified evidence for two of our interventions of interest (beta-blockers and calcium channel blockers) and all evidence was of low or very low certainty. Further research is necessary to identify whether these treatments are effective at improving symptoms and whether there are any harms associated with their use.

Pharmacological interventions for acute attacks of vestibular migraine

BACKGROUND

Vestibular migraine is a form of migraine where one of the main features is recurrent attacks of vertigo. These episodes are often associated with other features of migraine, including headache and sensitivity to light or sound. The unpredictable and severe attacks of vertigo can lead to a considerable reduction in quality of life. The condition is estimated to affect just under 1% of the population, although many people remain undiagnosed. A number of pharmacological interventions have been used, or proposed to be used, at the time of a vestibular migraine attack to help reduce the severity or resolve the symptoms. These are predominantly based on treatments that are in use for headache migraine, with the belief that the underlying pathophysiology of these conditions is similar.  OBJECTIVES: To assess the benefits and harms of pharmacological interventions used to relieve acute attacks of vestibular migraine.

SEARCH METHODS

The Cochrane ENT Information Specialist searched the Cochrane ENT Register; Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE; Ovid Embase; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 September 2022.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and quasi-RCTs in adults with definite or probable vestibular migraine comparing triptans, ergot alkaloids, dopamine antagonists, antihistamines, 5-HT3 receptor antagonists, gepants (CGRP receptor antagonists), magnesium, paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs) with either placebo or no treatment.  DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were: 1) improvement in vertigo (assessed as a dichotomous outcome - improved or not improved), 2) change in vertigo (assessed as a continuous outcome, with a score on a numerical scale) and 3) serious adverse events. Our secondary outcomes were: 4) disease-specific health-related quality of life, 5) improvement in headache, 6) improvement in other migrainous symptoms and 7) other adverse effects. We considered outcomes reported at three time points: < 2 hours, 2 to 12 hours, > 12 to 72 hours. We used GRADE to assess the certainty of evidence for each outcome.  MAIN RESULTS: We included two RCTs with a total of 133 participants, both of which compared the use of triptans to placebo for an acute attack of vestibular migraine. One study was a parallel-group RCT (of 114 participants, 75% female). This compared the use of 10 mg rizatriptan to placebo. The second study was a smaller, cross-over RCT (of 19 participants, 70% female). This compared the use of 2.5 mg zolmitriptan to placebo.  Triptans may result in little or no difference in the proportion of people whose vertigo improves at up to two hours after taking the medication. However, the evidence was very uncertain (risk ratio 0.84, 95% confidence interval 0.66 to 1.07; 2 studies; based on 262 attacks of vestibular migraine treated in 124 participants; very low-certainty evidence). We did not identify any evidence on the change in vertigo using a continuous scale. Only one of the studies assessed serious adverse events. No events were noted in either group, but as the sample size was small we cannot be sure if there are risks associated with taking triptans for this condition (0/75 receiving triptans, 0/39 receiving placebo; 1 study; 114 participants; very low-certainty evidence).  AUTHORS' CONCLUSIONS: The evidence for interventions used to treat acute attacks of vestibular migraine is very sparse. We identified only two studies, both of which assessed the use of triptans. We rated all the evidence as very low-certainty, meaning that we have little confidence in the effect estimates and cannot be sure if triptans have any effect on the symptoms of vestibular migraine. Although we identified sparse information on potential harms of treatment in this review, the use of triptans for other conditions (such as headache migraine) is known to be associated with some adverse effects.  We did not identify any placebo-controlled randomised trials for other interventions that may be used for this condition. Further research is needed to identify whether any interventions help to improve the symptoms of vestibular migraine attacks and to determine if there are side effects associated with their use.

Altered large-scale internetwork functional connectivity in patients with vestibular migraine and migraine without aura

OBJECTIVE

To investigate large-scale internetwork functional connectivity in patients with vestibular migraine (VM) and migraine without aura (MwoA).

METHODS

Resting-state functional magnetic resonance imaging data from 34 VM patients, 34 MwoA patients, and 33 healthy controls (HCs) were collected and the results were analyzed using independent component analysis (ICA). We also analyzed the correlations between clinical data and internetwork functional connectivity.

RESULTS

In contrast to HCs, MwoA patients showed decreased functional connectivity between the left frontoparietal network (lFPN) and right frontoparietal network (rFPN), with increased functional connectivity between the sensorimotor network (SMN) and lateral visual network (lVN). When compared to MwoA patients, VM patients demonstrated decreased functional network connectivity between the dorsal attention network (DAN) and posterior medial visual network (pmVN), between the SMN and pmVN, and between the SMN and lVN. Meanwhile, increased functional network connectivity was found between the lFPN and rFPN; however, there was no significant difference in functional network connectivity between VM patients and HCs. In addition, associations were found between clinical data and internetwork functional connectivity.

CONCLUSION

Functional connectivity between the lFPN and rFPN was reduced in patients with MwoA compared with HCs, which may indicate functional impairment in cognitive control, attention, somatosensory perception, and emotion regulation in patients with MwoA. VM patients showed decreased functional connectivity between the DAN, SMN, pmVN and lVN compared to patients with MwoA, which could account for the multisensory integration abnormalities and be the cause of vestibular symptoms in VM patients. These findings offer fresh perspectives on the pathophysiology of VM and MwoA.

Dizziness After Traumatic Brain Injury: A Prospective TRACK-TBI Analysis of Risk Factors, Quality of Life, and Neurocognitive Effects

OBJECTIVE

To determine the longitudinal incidence of dizziness and its association with demographic factors, neurocognitive effects, functionality, and quality of life.

STUDY DESIGN

Transforming Research and Clinical Knowledge in Traumatic Brain Injury (TRACK-TBI) is a prospective, longitudinal cohort study in which TBI patients were assessed at the emergency department and 2-week, 3-month, 6-month, and 12-month follow-up via telephone and/or in-person visits.

SETTING

Multicenter study in emergency departments of 18 academic medical centers in the United States.

PATIENTS

A total of 1,514 patients 17 years or older with a diagnosis of TBI, injury occurrence within 24 hours of admission, fluency in English or Spanish, and completed Rivermead Post-Concussion Symptoms Questionnaire (RPQ) at 12 months were enrolled between February 2014 and August 2018.

MAIN OUTCOME MEASURE

RPQ, Short Form-12 Version 2, Wechsler Adult Intelligence Scale IV, Trail Making Test, Patient Health Questionnaire-9, PROMIS-PAIN, and Glasgow Outcome Scale-Extended Revised. The primary outcome measure was a self-report of "feelings of dizziness" on RPQ at 12 months post-TBI.

RESULTS

Of the 1,514 participants, 1,002 (66%) were male and 512 (34%) were female. The mean age was 41.6 (SD, 17.4) years. At 12 months, 26% experienced dizziness, with 9% experiencing moderate or severe dizziness. Dizziness was strongly associated with headache (odds ratio [OR], 3.45; 95% confidence interval [CI], 2.92-4.07; p < 0.001), nausea (OR, 4.43; 95% CI, 3.45-5.69; p < 0.001), worse hearing (OR, 3.57; 95% CI, 2.64-4.82; p < 0.001), noise sensitivity (OR, 3.02; 95% CI, 2.54-3.59; p < 0.001), and light sensitivity (OR, 3.51; 95% CI, 2.91-4.23; p < 0.001). In multivariable regression models, participants with severe dizziness demonstrated lower performance compared with those without new or worse dizziness on the Wechsler Adult Intelligence Scale IV (-6.64; p < 0.001), Trail Making Test part A (7.90; p = 0.003) and part B (19.77; p = 0.028), and Short Form-12 physical (-13.60; p < 0.001) and mental health (-11.17; p < 0.001), after controlling for age, sex, education, and TBI severity.

CONCLUSION

Dizziness is common among TBI patients and relates to quality of life and neurocognitive performance.

Prevalence of Polypharmacy in Patients With Vestibular and Balance Complaints

OBJECTIVES

To determine the prevalence of polypharmacy in patients presenting with dizziness to a tertiary neurotology clinic and analyze the association between polypharmacy and clinical characteristics.

DESIGN

Retrospective, cross-sectional review. Demographics, symptoms, diagnoses, medications, audiometry, dizziness handicap index (DHI) scores, and cognitive failure questionnaire (CFQ) scores were extracted from charts of patients seen as new patients from September 1, 2019, to March 31, 2020, with a primary complaint of dizziness.

RESULTS

A total of 382 patients were included. More than two-thirds of the patients (n = 265, 69.4%) met criteria for polypharmacy (≥5 medications), of which most (n = 249, 94.0%) were prescribed a potentially ototoxic drug. Approximately 10% of patients were taking five or more ototoxic medications (oto-polypharmacy). Polypharmacy was correlated to age and was more common for patients with diabetes, hypertension, other cardiovascular comorbidities, and depression (odds ratio [OR], 3.73-6.67; p < 0.05). Polypharmacy was twice as likely in patients with mild to moderate hearing loss (OR 2.02 [1.24-3.29] and OR 2.13 [1.06-4.27], respectively; p < 0.05) and ~1.5× more likely in patients who had moderate to severe DHI scores (OR 1.65 [1.05-2.59] and OR 1.63 [1.00-2.65], respectively; p < 0.05). Patients with polypharmacy also had higher CFQ scores compared to those without polypharmacy (CFQ 32.5 [19.0-48.0] versus CFQ 25.0 [13.0-40.0]; p = 0.002. Oto-polypharmacy was more common for patients with lightheadedness as a dizziness descriptor (OR 3.16 [1.56-6.41]; p < 0.01). However, oto-polypharmacy was only more common for patients with mild to moderate hearing loss (OR 2.69 [1.33-5.45] and OR 2.86 [1.31-6.20], respectively; p < 0.01) and severe DHI scores (2.31 [1.12-4.77], p = 0.02).

CONCLUSIONS

The prevalence of polypharmacy in patients with vestibular disorders is high. Some of the medications that patients are on are also potentially ototoxic at variable degrees. Polypharmacy is more common when lightheadedness is one of the dizziness descriptors and seems to be associated with worse scores on patient-reported outcome measures (DHI, CFQ). Medication reconciliation and multidisciplinary involvement could help to better address polypharmacy in this patient population. However, further investigation is needed to elucidate polypharmacy's role in symptom presentation, vestibular testing results, and therapeutic strategies.

Pathophysiology and Therapy of Associated Features of Migraine

Migraine is a complex and debilitating disorder that is broadly recognised by its characteristic headache. However, given the wide array of clinical presentations in migraineurs, the headache might not represent the main troublesome symptom and it can even go unnoticed. Understanding migraines exclusively as a pain process is simplistic and certainly hinders management. We describe the mechanisms behind some of the most disabling associated symptoms of migraine, including the relationship between the central and peripheral processes that take part in nausea, osmophobia, phonophobia, vertigo and allodynia. The rationale for the efficacy of the current therapeutic arsenal is also depicted in this article. The associated symptoms to migraine, apart from the painful component, are frequent, under-recognised and can be more deleterious than the headache itself. The clinical anamnesis of a headache patient should enquire about the associated symptoms, and treatment should be considered and individualised. Acknowledging the associated symptoms as a fundamental part of migraine has permitted a deeper and more coherent comprehension of the pathophysiology of migraine.

Vestibular migraine treatment: a comprehensive practical review

Vestibular migraine is an underdiagnosed but increasingly recognised neurological condition that causes episodic vertigo associated with other features of migraine. It is now thought to be the most common cause of spontaneous (non-positional) episodic vertigo, affecting up to 1% of the population. A meta-analysis of preventative treatments for vestibular migraine was published in 2021 but the authors were unable to establish a preferred treatment strategy due to low quality of evidence and heterogeneity of study design and outcome reporting. There remains therefore a clinical need for pragmatic management guidelines specific to vestibular migraine using the available evidence. Here we provide a practical review utilising a systematic qualitative assessment of the evidence for abortive and preventative interventions in adults. The overall evidence base for vestibular migraine treatment is of low quality. Nevertheless, we provide practical treatment recommendations based on the available evidence and our experience to help guide clinicians treating patients with vestibular migraine. We also discuss how future clinical trials could be designed to improve the quality of evidence in this condition.

Pediatric vestibular migraine: Diagnosis according to ICHD-3 criteria and the effectiveness of short-term CH prophylaxis

OBJECTIVE

Vestibular migraine (VM) is a rare migraine variant with limited information about its treatment in children. This study, it was aimed to evaluate the diagnostic characteristics of VM in children and the effectiveness of cyproheptadine hydrochloride (CH) prophylaxis.

METHODS

Patients aged 6-18 years who were diagnosed with VM and other primary headaches (OPHs) according to ICHD-3 diagnostic criteria and given oral CH prophylaxis for at least 3 months were included in the study. Response to CH prophylaxis was defined by the change in symptoms (worsening, no change, and improvement) monthly.

RESULTS

A total of 64 cases diagnosed with primary headache and given CH prophylaxis were identified. 40.6% (29) migraine without aura of patients, 34.4% (22) VM, 14.1% (9) tension type headache, 4.7% (3) benign paroxysmal vertigo, 3.1% (2) migraine with aura and 3.1% (2) were diagnosed with abdominal migraine. Compared to OPHs, it was found that the duration of headache attack was shorter (p .013) and vomiting, which is one of the associated symptoms, was observed less in pediatric VM (p .032). The positive response of the whole study population to CH prophylaxis was 85.9%. However, CH prophylaxis responses were higher in VM compared to OPHs at the end of 1 month (63.6%) and 2 months (86.3%).

CONCLUSION

In the pediatric population, the migrainous characters of VM may show differences, but its response to short-term CH prophylaxis is quite good.

Vestibular migraine

Vestibular migraine is an under-diagnosed but increasingly recognised neurological condition that causes episodic vertigo, associated with migrainous features. Making a diagnosis of VM relies on a clinical history, including the presence of recurrent episodes of vertigo or dizziness, on a background of migraine headaches, and associated migraine features that accompany the vestibular symptoms. It is the most common cause of spontaneous (non-positional) episodic vertigo, affecting up to 1% of the population, but remains under-diagnosed outside specialist centres, partly due to an absence of diagnostic biomarkers. Its pathophysiology remains poorly understood, and there is a paucity of high-quality treatment trials. Here we review the clinical features of vestibular migraine, highlight current theories that account for vestibular symptoms, and outline treatment guidelines.

Exploring Vestibular Assessment in Patients with Headache and Dizziness

Patients often report symptoms of headache and dizziness concomitantly. Symptoms of dizziness can be explored with a comprehensive vestibular assessment, allowing for the investigation of central and peripheral vestibular system contributions to symptoms of dizziness. Patients who report both symptoms of headache and dizziness demonstrate abnormalities of the vestibular system which can be measured quantitatively. Completion of comprehensive vestibular testing can help to guide diagnosis and strategies for intervention.

Patient Experience of Flunarizine for Vestibular Migraine: Single Centre Observational Study

Vestibular migraine (VM) is a leading cause of episodic vertigo, affecting up to 1% of the general population. Despite established diagnostic criteria, there is currently no evidence-based approach for acute treatment of VM, with treatment recommendations generally extrapolated from studies on classical migraine headache. Several small-scale studies have identified flunarizine as a potentially effective prophylactic medication in VM. We conducted a single-centre observational service evaluation study exploring patient experiences of preventative medications over a 28-month period, including flunarizine, for control of VM symptoms. To compare patient experience of flunarizine with other medications, data from patients taking flunarizine were separately analysed. A total of 90% of VM patients taking flunarizine reported symptomatic improvement, compared to only 32% of patients on other medications. Whilst 50% of patients on flunarizine reported side effects. these were not deemed to outweigh the clinical benefits, with most patients deciding to continue treatment. Our data supports the use of flunarizine in VM.

Pharmacotherapy of cerebellar and vestibular disorders

PURPOSE OF REVIEW

Major therapeutic advances have been made in patients with episodic and progressive cerebellar ataxias, downbeat nystagmus and some vestibular disorders. We provide an update review on this subject highlighting important research findings from the last two years.

RECENT FINDINGS

Recently, the use of omaveloxolone for 2 years significantly improved upright stability in Friedreich's ataxia patients. In an open-label study, N-acetyl-l-leucine administered for 6-weeks significantly improved clinical impression of change, ataxia, and quality of life in patients with Niemann-Pick disease type C1. A 12-week treatment with dalfampridine was associated with improved standing balance in a subgroup of patients with multiple sclerosis. A gluten-free diet alone improved ataxia in half of patients with antiglutamic acid decarboxylase (GAD) ataxia, suggesting that gluten sensitivity might be part of the underlying pathogenesis in anti-GAD ataxia. In a head-to-head trial, both prolonged-release 4-aminopyridine (4-AP) and acetazolamide effectively reduced the attacks up to 60% in patients with episodic ataxia type 2 (EA2), albeit 4-AP had fewer adverse effects. Small observational studies have shown that patients with episodic vestibular syndrome who cannot be diagnosed as definite or probable vestibular migraine, might still improve vestibular symptoms following preventive treatment for migraine. The use of vitamin D supplementation in benign paroxysmal positional vertigo, steroids in acute unilateral vestibulopathy, and betahistine in Ménière's disease patients remains controversial.

SUMMARY

Although the use of several therapies is being established in the treatment of cerebellar and vestibular disorders, there is an urgent need for prospective controlled therapeutic trials.

Care Gaps and Recommendations in Vestibular Migraine: An Expert Panel Summit

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.

Vestibular migraine: Diagnostic criteria1

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). It contains a literature update while the original criteria from 2012 were left unchanged. The classification defines vestibular migraine and probable vestibular migraine. Vestibular migraine was included in the appendix of the third edition of the International Classification of Headache Disorders (ICHD-3, 2013 and 2018) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.

A Comparison of Falls and Dizziness Handicap by Vestibular Diagnosis

PURPOSE

There is a paucity of data that directly compares the falls rate and dizziness handicap of different vestibular diagnoses. The purpose of this study is to compare the falls rate and dizziness handicap of common vestibular diagnoses encountered among a cohort of vestibular patients at a single institution.

METHOD

We conducted a retrospective cross-sectional study of patients evaluated for dizziness at a tertiary care center vestibular clinic between August 1, 2017, and March 19, 2019. Vestibular diagnosis, demographic variables, comorbidities, falls status, and Dizziness Handicap Inventory (DHI) were extracted from the medical record for analysis. Associations between vestibular diagnosis and falls history or DHI were evaluated using multivariate logistic and linear regression, respectively.

RESULTS

A total of 283 patients met our inclusion criteria with the following diagnoses: benign paroxysmal positional vertigo (BPPV; n = 55), acoustic neuroma (n = 30), Ménière's disease (n = 28), multiple vestibular diagnoses (n = 15), vestibular migraine (n = 135), or vestibular neuritis (n = 20). After adjusting for age, sex, race, medications, and comorbidities, the odds of falling was 2.47 times greater (95% CI [1.08, 6.06], p = .039) and the DHI score was 11.66 points higher (95% CI [4.99, 18.33], p < .001) in those with vestibular migraine compared to those with BPPV. Other diagnoses were comparable to BPPV with respect to odds of falling and dizziness handicap.

CONCLUSIONS

Patients with vestibular migraine may suffer an increased risk of falls and dizziness handicap compared to patients with BPPV. Our findings highlight the need for timely evaluation and treatment of all patients with vestibular disease.

The visual-ocular and vestibulo-ocular reflexes in vestibular migraine

Vestibular migraine is a disease from the border of neurology and otoneurology. The diagnosis depends on patient history. There are no valuable laboratory or imaging tests, therefore the examination of visual-ocular and vestibulo-ocular reflexes is very useful in this group of patients. The material was collected from patients diagnosed due to dizziness at the Department of Otolaryngology and Oncology with the Subdepartment of Audiology and Phoniatrics, CM UMK in Bydgoszcz in 2019–2021. We considered patients with vestibular migraine and analyzed videonystagmographic tests in this study. The most common VNG abnormalities in patients suffering from vestibular migraine were an increased labyrinthine response, increased time constant of the rotational response and abnormal optokinetic response. There was not a single case of canal paresis in the group of patients with vestibular migraine.

Current and Emerging Medical Therapies for Dizziness

Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.

Chronic Central Vestibulopathies for the Otolaryngologist

Central vestibulopathies involve disorders of the central nervous system that lead to problems with balance, often manifested as dizziness, vertigo, and gait difficulty. Central vestibulopathies can be distinguished from peripheral vestibulopathies with the use of certain tests, including nystagmography and posturography. The neuroanatomy of individuals with central vestibulopathies can reveal structural abnormalities in the posterior cerebrum or cerebellum. Various medications can be used to manage central vestibulopathies, including vestibular migraine.

Clinical features of definite vestibular migraine through the lens of central sensitization: a cross-sectional study

BACKGROUND

Vestibular migraine (VM) commonly causes episodic vertigo/dizziness; however, its clinical features are unknown. Based on the evidence that central sensitization is related to VM pathogenesis, we hypothesized that cutaneous allodynia is frequently associated with patients with VM compared with patients without VM. This study aims to (1) elucidate the clinical features of patients with VM and (2) evaluate whether patients with VM were more frequently associated with cutaneous allodynia than patients without VM.

METHODS

This cross-sectional study enrolled consecutive patients with migraine aged 18-65 years. The comprehensive interview form included diagnostic questions regarding migraine and VM, demographic characteristics, migraine-specific variables, migraine-associated symptoms, and cutaneous allodynia.

RESULTS

A total of 245 consecutive patients with migraine (mean age = 39.5 years, 81.2% women) were enrolled; 65 (26.5%) patients with VM were assigned to the VM group, 74 (30.2%) with migraine with vestibular symptoms not meeting the VM criteria (MwVS) were assigned to the MwVS group, and 106 (43.3%) patients with episodic migraine without vestibular symptoms (EM) were assigned to the EM group, respectively. Pairwise comparisons demonstrated no significant differences between the VM and MwVS groups, except for severe disability in the VM group. Compared with EM group, VM group had significant aura, severe disability, depression, tinnitus, sleep disorders, and widespread multimodal cutaneous allodynia.

CONCLUSIONS

VM and MwVS may be on the same spectrum of disorders. The VM group had significantly associated widespread multimodal cutaneous allodynia compared with the EM group, indicating that thalamic sensitization plays a key role in VM pathogenesis. Widespread allodynia may be a useful diagnostic aid for VM.

Vestibular Migraine and Its Comorbidities

Vestibular migraine (VM) is one of the most common neurologic causes of vertigo. Symptoms and International Classification of Headache Disorders criteria are used to diagnose VM because no objective tests, imaging or audiologic, have been shown to reliably diagnose this condition. Central auditory, peripheral, and central vestibular pathway involvement has been associated with VM. Although the interaction between migraine and other vestibular disorders can be a challenging scenario for diagnosis and treatment, there are data to show that vestibular rehabilitation and a variety of pharmacologic agents improve reported symptoms and vertigo frequency.

Current Insights into Treating Vertigo in Older Adults

The number of older people has been increasing over recent decades in Western populations. Dizziness, imbalance, and vertigo constitute some of the most common complaints in older patients, and risk of falling is the most frequent and worrying consequence. It has been reported that 15–20% of the adult population experiences these debilitating symptoms. Among the diseases that may be associated with vertigo, the three classes of otological, central, and functional (psychological) dizziness may be distinguished. Overall, vestibular disorders account for 48% of vertiginous complaints in the older population. The main focus of this article is to review the forms of pharmacotherapy for vertigo, especially with regard to older patients, who may be treated simultaneously with other drugs for different comorbidities. Interactions with other drugs should be considered in the choice of a particular course of treatment. Moreover, overuse of pharmacotherapy for the management of vertigo in the elderly may prevent the development of the central compensatory mechanism that sustains both static and dynamic imbalance after a vertiginous crisis. In the majority of patients, vestibular and physical rehabilitation are strongly advised and rarely contraindicated.

The effectiveness of propranolol, flunarizine, amitriptyline and botulinum toxin in vestibular migraine complaints and prophylaxis: a non-randomized controlled study

Introduction

Vestibular migraine is the most common cause of spontaneous episodic vertigo in adult patients and the second most common cause of vertigo in patients of all ages.

Objective

To assess the effectiveness of oral medication type (propranolol, flunarizine, and amitriptyline) and botulinum toxin A application on vestibular symptoms, headache severity and attack frequency for vestibular migraine patients.

Methods

Sixty patients with vestibular migraine were enrolled. Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B− group). Headache severity was evaluated with Migraine Disability Assessment Scale and vertigo severity was evaluated with Dizziness Handicap Inventory scale. Vestibular migraine attack frequencies in the last three months were also evaluated.

Results

There was a statistically significant decrement in mean Dizziness Handicap Inventory scores, Migraine Disability Assessment Scale scores and vertigo attack frequencies after treatment for all patients, B+ and B− group patients (p < 0.001 for all). The mean Migraine Disability Assessment Scale score gains (p < 0.001) and vertigo attack frequency gains (p =  0.003) were significantly higher in the B+ patients than B− patients.

Conclusions

Both B+ and B− group patients exhibited significant improvement in vestibular migraine attack frequencies, Dizziness Handicap Inventory score and Migraine Disability Assessment Scale score values. However, botulinum toxin A application had a more pronounced effect for Migraine Disability Assessment Scale score gain and vestibular migraine attack frequency values, but not for Dizziness Handicap Inventory score gain values. Thus, botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. The oral medication type (propranolol, flunarizine or amitriptyline) did not differ in influencing the vestibular migraine attack frequency, Dizziness Handicap Inventory score gain and Migraine Disability Assessment Scale score gain values.

Neuropsychiatric Consequences of Lipophilic Beta-Blockers

Beta-blockers are a class of drugs with important benefits in cardiovascular pathology. In this paper, we aim to highlight their adverse and therapeutic effects in the neuropsychiatric field. With respect to permeability, we would like to mention that most beta-blockers are lipophilic and can cross the blood–brain barrier. Observational studies show the presence of neuropsychiatric side effects when taking beta-blockers, and is the reason for which caution is recommended in their use in patients with depressive syndrome. From a therapeutic point of view, most current evidence is for the use of beta-blockers in migraine attacks, essential tremor, and akathisia. Beta-blockers appear to be effective in the treatment of aggressive behavior, beneficial in the prevention of posttraumatic stress syndrome and may play a role in the adjuvant treatment of obsessive–compulsive disorder, which is refractory to standard therapy. In conclusion, the relationship between beta-blockers and the central nervous system appears as a two-sided coin. Summarizing the neuropsychiatric side effects of beta-blockers, we suggest that clinicians pay special attention to the pharmacological properties of different beta-blockers.

Cinnarizine as an alternative recommendation for migraine prophylaxis: a narrative review

INTRODUCTION

Despite the available prophylactic and acute drugs for migraine management, this disabling disorder remains undertreated especially among pediatrics. In this review, the authors aim at assessing the preventive role cinnarizine plays in treating migraine based on previously published studies.

AREAS COVERED

Randomized clinical trials, randomized controlled trials, non-randomized open-label trials, and retrospective studies concerning cinnarizine in migraine prevention in children and adults were reviewed. Especial attention was given to the response rate, migraine characteristics, and tolerability.

EXPERT OPINION

The majority of reviewed trials demonstrated that cinnarizine is comparable to the conventional drugs used in migraine prophylaxis. However, most of the reviewed studies were limited by a non-controlled open-label design. Due to poor planning and possibility of high placebo responses, particularly in children and adolescents, the interpretation of open-label studies' results should be done cautiously. The evidence shows that cinnarizine's effectiveness was more promising in pediatric migraineurs and adults with migraine-associated vertigo such as vestibular migraine. Therefore, while the efficacy of cinnarizine cannot be dismissed, before reaching a definite conclusion on its effectiveness, it is necessary to do further high-quality RCTs among both children and adults.