Current Treatment Options: Vestibular Migraine

Efficacy of a Serotonin-Norepinephrine Reuptake Inhibitor as a Treatment for Meniere Disease: A Randomized Clinical Trial

Importance

Meniere disease accounts for up to 15% of new vestibular diagnoses,; however, the optimal treatment has yet to be identified. A conservative treatment that would reduce or stop the vertigo episodes has not been identified.

Objective

To determine the efficacy of a serotonin-norepinephrine reuptake inhibitor, venlafaxine, compared to placebo in treating patients with Meniere disease.

Design, Setting, and Participants

This was a randomized, double-blind, placebo-controlled, crossover pilot study spanning 22 weeks of follow-up. The clinical trial took place at a single-center tertiary referral center in Charleston, South Carolina. Participants were eligible if they were 18 years or older, had definite Meniere disease criteria as defined by Barany criteria, had at least 2 episodes in the last month, had not received intratympanic gentamycin, skull base surgery, or radiation therapy to the head or neck, not currently taking diuretics for Meniere disease, not currently taking oral steroids, and not currently taking serotonin-modulating medication. Patients were enrolled between February 2020 and September 2023.

Interventions

Patients received either 1 venlafaxine tablet, 37.5 mg, taken daily by mouth for 8 weeks or 1 placebo tablet taken daily by mouth for 8 weeks. Group 1 received placebo during phase 1 of the trial and venlafaxine in phase 2 of the trial. Group 2 received venlafaxine during phase 1 of the trial and placebo in phase 2 of the trial.

Main Outcomes and Measures

The main outcomes included the number of episodes and scores on the following scales: Dizziness Handicap Inventory, Neuropsychological Vertigo Inventory, Meniere Disease Patient-Oriented Symptom Index, 20-Item Short Form Health Survey, Penn State Worry Questionnaire, Cognitive Failure Questionnaire.

Results

A total of 182 patients were screened, and 40 participants with Meniere disease enrolled in the trial. The mean (SD) age of participants was 56.6 (14.3) years, and 22 (55%) were female. Participants had a mean (SD) of 13.8 (10.1) episodes per phase at baseline, 5.4 (4.4) episodes (Δ8.4) during the venlafaxine phase, and 5.0 (4.6) episodes (Δ8.8) during the placebo phase. No significant difference was identified between venlafaxine and placebo groups in the number of episodes or quality-of-life metrics.

Conclusions and Relevance

This randomized clinical trial failed to identify a difference between venlafaxine and placebo in number of episodes and other quality-of-life metrics. Future studies may benefit from different dosing regimens, larger cohorts, and longer lengths of therapy.

Trial Registration

ClinicalTrials.gov Identifier: NCT04218123.

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.

Breaking the cycle: unraveling the diagnostic, pathophysiological and treatment challenges of refractory migraine

Background

Refractory migraine is a poorly described complication of migraine in which migraine has chronified and become resistant to standard treatments. The true prevalence is unknown, but medication resistance is common in headache clinic patient populations. Given the lack of response to treatment, this patient population is extremely difficult to treat with limited guidance in the literature.

Objective

To review the diagnostic, pathophysiological, and management challenges in the refractory migraine population.

Discussion

There are no accepted, or even ICHD-3 appendix, diagnostic criteria for refractory migraine though several proposed criteria exist. Current proposed criteria often have low bars for refractoriness while also not meeting the needs of pediatrics, lower socioeconomic status, and developing nations. Pathophysiology is unknown but can be hypothesized as a persistent "on" state as a progression from chronic migraine with increasing central sensitization, but there may be heterogeneity in the underlying pathophysiology. No guidelines exist for treatment of refractory migraine; once all guideline-based treatments are tried, treatment consists of n-of-1 treatment trials paired with non-pharmacologic management.

Conclusion

Refractory migraine is poorly described diagnostically, its pathophysiology can only be guessed at by extension of chronic migraine, and treatment is more the art than science of medicine. Navigating care of this refractory population will require multidisciplinary care models and an emphasis on future research to answer these unknowns.

Course of Duration and Trigger Factors of Vertigo Attacks in Patients with Benign Recurrent Vertigo, Menière's Disease, or Vestibular Migraine

INTRODUCTION

Benign recurrent vertigo (BRV), Menière's disease (MD), and vestibular migraine (VM) show many similarities with regard to the course of vertigo attacks and clinical features. In this paper, we elaborate on the decreasing frequency of vertigo attacks observed in a previous study from our group by exploring changes in the duration and trigger factors of vertigo attacks in patients with BRV, MD, or VM.

METHODS

For this 3-year prospective cohort study in our tertiary referral center we recruited patients with a confirmed diagnosis of BRV, MD, or VM by a neurologist and otorhinolaryngologist in our center in 2015-2016. A study-specific questionnaire was used to assess the usual duration of vertigo attacks and their potential triggers every 6 months. Main outcome measures were changes in duration and trigger factors of vertigo attacks in the subgroups of patients with persisting attacks, which were analyzed using repeated measures logistic regression models.

RESULTS

121 patients were included (BRV: n = 44; MD: n = 43; VM: n = 34) of whom 117 completed the 3-year follow-up period and 57 (48.7%) kept reporting vertigo attacks at one more follow-up measurements. None of the diagnosis groups showed statistically significant shortening of attack duration at the subsequent annual follow-up measurements compared to baseline. At baseline, stress and fatigue being reported as triggers for attacks differed significantly between the three groups (stress: BRV 40.9%, MD 62.8%, VM 76.5%, p = 0.005; fatigue: BRV 31.0%, MD 48.8%, VM 68.8%, p = 0.003). In the VM group, a consistent reduction of stress and fatigue as triggers was observed up until the 24- and the 30-month follow-up measurements, respectively, with odds ratios (ORs) ranging from 0.15 to 0.33 (all p < 0.05). In the MD group, a consistent reduction of head movements as trigger was observed from the 24-month measurement onward (ORs ranging from 0.07 to 0.11, all p < 0.05).

CONCLUSION

Our study showed no reduction in vertigo attack duration over time in patients with BRV, MD, and VM who remain to have vertigo attacks. In VM and MD patients with persisting vertigo attacks stress, fatigue and head movements became less predominant triggers for vertigo attacks.

Treating Vestibular Migraine When Pregnant and Postpartum: Progress, Challenges and Innovations

Vestibular migraine is a leading cause of vertigo in pregnancy and, although not a distinct migraine subtype, is an episodic syndrome associated with migraine. Vestibular migraine is associated with diverse symptoms such as vertigo, aura, allodynia, osmophobia, nausea, vomiting and tinnitus, many of which may be exacerbated by, masked or even dismissed in pregnancy. Vestibular migraine is likely an underdiagnosed and undertreated condition in pregnancy. The aetiology of vestibular migraine remains incompletely understood, although various theories have been proposed, including genetic predisposition, neurochemical dysregulation and pro-inflammatory mechanisms, all of which are derived from the pathophysiology of classical migraine. Physiologic changes to the endocrine, haematologic and vascular systems in pregnancy may affect pathophysiological processes in vestibular migraine, and can alter the course of symptoms experienced in pregnancy. These changes also predispose to secondary headache disorders, which may have similar presentations. There has been considerable progress in therapeutic advances in vestibular migraine prophylaxis and treatment outside of pregnancy. There is currently no significant evidence base for acute treatment or prophylaxis for pregnant patients, with treatment recommendations extrapolated from studies on classical migraine, and offered on a benefit versus risk basis. Challenges commonly encountered include difficulty establishing a diagnosis, in addition to recognising and treating neuropsychiatric and gestational co-morbidities. Anxiety, depression, hypertensive disorders and cardiovascular disease are closely associated with migraine, and important contributors to morbidity and mortality during pregnancy. Identifying and treating vestibular migraine during pregnancy offers a unique opportunity to impact future patient health through screening and early treatment of associated co-morbidities. There have been innovations in classical migraine therapy that may confer benefit in vestibular migraine in pregnancy, with emphasis on lifestyle modification, effective prophylaxis, abortive therapies, cognitive behaviour therapy and management of vestibular migraine-related comorbidities.

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.

Repurposable Drugs That Interact with Steroid Responsive Gene Targets for Inner Ear Disease

Corticosteroids, oral or transtympanic, remain the mainstay for inner ear diseases characterized by hearing fluctuation or sudden changes in hearing, including sudden sensorineural hearing loss (SSNHL), Meniere's disease (MD), and autoimmune inner ear disease (AIED). Despite their use across these diseases, the rate of complete recovery remains low, and results across the literature demonstrates significant heterogeneity with respect to the effect of corticosteroids, suggesting a need to identify more efficacious treatment options. Previously, our group has cross-referenced steroid-responsive genes in the cochlea with published single-cell and single-nucleus transcriptome datasets to demonstrate that steroid-responsive differentially regulated genes are expressed in spiral ganglion neurons (SGN) and stria vascularis (SV) cell types. These differentially regulated genes represent potential druggable gene targets. We utilized multiple gene target databases (DrugBank, Pharos, and LINCS) to identify orally administered, FDA approved medications that potentially target these genes. We identified 42 candidate drugs that have been shown to interact with these genes, with an emphasis on safety profile, and tolerability. This study utilizes multiple databases to identify drugs that can target a number of druggable genes in otologic disorders that are commonly treated with steroids, providing a basis for establishing novel repurposing treatment trials.

The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach

Objective:

The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting.

Study design:

Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction.

Results:

Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form.

Conclusion:

The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.

Central vestibular dysfunction: don't forget vestibular rehabilitation

INTRODUCTION

Vestibular rehabilitation (VR) is now a subject of active studies and has been shown to be effective for multiple vestibular disorders, peripheral or central. VR is a physical therapy that helps train the central nervous system to compensate for vestibular dysfunction. There is moderate to strong evidence that VR is safe and effective for the management of peripheral vestibular dysfunction. Nonetheless, the studies on how VR works on central vestibular dysfunction remains scanty.

AREAS COVERED

This article addressed the rehabilitation strategies and possible mechanisms, including how central vestibular function might improve upon rehabilitation. In addition, it provides some examples concerning the effect of VR on central vestibular dysfunction.

EXPERT OPINION

VR works on the vestibular system through repetition of specific physical exercises that activate central neuroplastic mechanisms to achieve adaptive compensation of the impaired functions. VR has become a mainstay in the management of patients with dizziness and balance dysfunction. Individualized VR programs are a safe and effective treatment option for a large percentage of patients with central vestibular disease reporting imbalance and dizziness. Exploration of various treatment strategies and possible mechanisms will help develop the best and personalized VR treatment for patients with central vestibular dysfunction.

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.

Effects of Lifestyle Modification on Vestibular Migraine

OBJECTIVE

To evaluate effects of lifestyle modification on symptoms of dizziness and headache in patients diagnosed with definite vestibular migraine.

STUDY DESIGN

Prospective within-participants repeated-measures study.

SETTING

Otolaryngology tertiary care.

PARTICIPANTS

Twenty-eight adults with definite vestibular migraine who were willing to be treated without pharmacological intervention.

INTERVENTIONS

Information and instructions were provided on lifestyle modification; participants were instructed to improve restful sleep, exercise, eat at regulated mealtimes, and avoid dietary triggers. Participants were asked to maintain the modifications for at least 60 days.

MAIN OUTCOME MEASURES

Two self-report inventories were used pre- and post-intervention to evaluate participants' perceived dizziness handicap and headache disability using the Dizziness Handicap Inventory and Headache Disability Inventory, respectively. Questions were also used to evaluate the extent to which participants reported compliance with lifestyle factors pre- and post-intervention.

RESULTS

Significant improvement was observed after the lifestyle intervention with mean improvements in Dizziness Handicap Inventory and Headache Disability Inventory of 14.3 points. As a group, improvement in restful sleep was related to improvement in both dizziness and headache symptoms. At the individual participant level, 39% and 18% of participants reported significant reduction in dizziness handicap and headache disability, respectively.

CONCLUSIONS

Lifestyle modifications are an effective intervention for symptoms of dizziness and headache in participants with definite vestibular migraine. Participants who reported a larger increase in restful sleep were more likely to also report larger improvements in dizziness handicap and headache disability. Effect sizes using the current intervention were comparable or better than some reported pharmacological interventions but less than others. Our lifestyle modification intervention produced significant improvement in dizziness for a larger percentage of individual participants and in headache for a similar percentage of participants compared to data reported with other lifestyle modification interventions. Lifestyle modifications, especially restful sleep, have the potential to reduce the impact of vestibular migraine on patients' lives, with limited risk.Clinical Trials Registration: NCT03979677.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine

OBJECTIVE

Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine.

METHODS

Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Pre- and post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively.

RESULTS

With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups.

CONCLUSION

With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit.

LEVEL OF EVIDENCE

Level III (evidence obtained from well-designed controlled trials without randomization).

Clinical significance of serum sex hormones in postmenopausal women with vestibular migraine: potential role of estradiol

OBJECTIVE

This study aimed to investigate the role of sex hormones in postmenopausal women with vestibular migraine.

METHODS

This observational study included 242 female patients with vestibular migraine who were postmenopausal during April 2017 to December 2019. Serum levels of sex hormones, including estradiol, progesterone, testosterone, follicle-stimulating hormone, luteinizing hormone, and prolactin, were determined by radioimmunoassay. The duration and frequency (every month) of onset of vestibular migraine were recorded. The degree of vestibular migraine was measured by the visual analogue scale.

RESULTS

Serum levels of estradiol, progesterone, and testosterone were significantly lower, while serum prolactin levels were significantly higher in postmenopausal patients with vestibular migraine compared with healthy controls. Serum estradiol levels were negatively correlated with the duration, frequency, and severity of onset of vestibular migraine. Patients with higher serum estradiol levels showed a longer disease-free survival time.

CONCLUSION

Sex hormones are correlated with vestibular migraine in postmenopausal women. Additionally, estradiol levels are correlated with the duration, frequency, and severity of onset of vestibular migraine, as well as the disease-free survival time.

The Treatment of Vestibular Migraine: A Narrative Review

Vestibular migraine (VM) is one of the most debilitating chronic diseases that is currently underdiagnosed and undertreated. The treatment of VM is a dynamic and rapidly advancing area of research. New developments in this field have the potential to improve the diagnosis and provide more individualized treatments for this condition. In this review, we discussed the progress of evidence-based treatment of VM, including pharmacotherapy and nonmedical methods. A search of the literature was conducted up to September 2019. In order to control or cure VM, patients should follow three steps. First, patients should comply with diet and behavioral medication; Second, during the attack of VM, patients should take medicine to control the symptoms. These acute attack treatment of VM consists of antiemetic medications (e.g., dimenhydrinate and benzodiazepines), anti-vertigo medicine, and analgesics (e.g. triptans). Third, prophylactic medicine (e.g., propranolol, topiramate, valproic aid, lamotrigine, and flunarizine) can be used to reduce the frequency and severity of VM attack. Also, vestibular rehabilitation (VR) treatment should be considered for all VM. Meanwhile, we also propose to establish a culture of prevention which is essential for reducing the personal, social and economic burden of VM.

Multifactorial Characteristics of Pediatric Dizziness and Imbalance

OBJECTIVES

To examine the relative prevalence of individual diagnoses in children and adolescents presenting with dizziness and/or imbalance, and to assess the proportion of patients assigned multiple contributing diagnoses.

STUDY DESIGN

Retrospective cohort study.

METHODS

We retrospectively reviewed our internal database of all patients seen at our pediatric vestibular program between January 2012 and March 2019 to determine the incidence of common diagnoses and groups of diagnoses for patients ages 21 or younger.

RESULTS

One thousand twenty-one patients were included with a mean age of 12.5 ± 4.9 years (range: 9 months-21 years). Of this total, 624 patients were female and 397 were male. Common diagnoses included vestibular migraine (VM; 35.0%), benign paroxysmal positional vertigo (BPPV; 21.6%), primary dysautonomia (15.7%), anxiety disorder (13.5%), and persistent postural perceptual dizziness (PPPD; 11.2%). A high proportion of patients (44.4%) received multiple contributing diagnoses. VM was frequently diagnosed with BPPV or PPPD, and 22 patients were diagnosed with all three concurrently.

CONCLUSION

The causes of dizziness and imbalance in the pediatric population are diverse, and many patients have multiple diagnoses that are often interrelated. It is important that providers recognize that the causes of vestibular symptoms in children and adolescents may be multifactorial and may span across multiple specialties.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:E1308-E1314, 2021.

Pharmacotherapy failure and progression to botulinum toxin injection in vestibular migraine

Objective

Given the lack of evidence on patients with medically refractory vestibular migraine, this study aimed to identify factors associated with pharmacotherapy failure and progression to botulinum toxin injection in vestibular migraine.

Methods

A retrospective cohort study was conducted on definite vestibular migraine patients from September 2015 to July 2019 who completed the Dizziness Handicap Inventory at least six weeks apart..

Results

The study comprised 47 patients (mean age = 50.2 ± 15.8 years), with a mean follow-up time of 6.0 ± 6.0 months. The mean pre-treatment Dizziness Handicap Inventory score was 57.5 ± 23.5, with a mean reduction of 17.3 ± 25.2 (p < 0.001) at last follow up. Oscillopsia (r = 0.458, p = 0.007), failure of first medication (r = 0.518, p = 0.001) and pre-treatment Dizziness Handicap Inventory question 15 (an emotional domain question) score (r = 0.364, p = 0.019) were the only variables significantly correlated with progression to botulinum toxin injection.

Conclusion

Motion hypersensitivity, failure of first medication, and fear of social stigmatisation suggest a decreased treatment response. These symptoms may require more aggressive treatment at an earlier stage.

Vestibular migraine without headache treated with lomerizine: A 35-year-old woman undiagnosed for 10 years

A 35-year-old woman presented with recurrent vertigo without headache, which had persisted for 10 years. Detailed medical history revealed that she experienced hearing loss, tinnitus, nausea, photophobia, phonophobia, and slight discomfort in the head during vertigo attacks, which often led to absence from work. Based on the diagnostic criteria of the International Classification of Headache Disorders, third edition, she was diagnosed with vestibular migraine and was prescribed lomerizine, as prophylaxis. Her symptoms markedly improved, enabling her to go to work. Accurate diagnosis and treatment are important for improving the quality of life of patients, since vestibular migraine is commonly underdiagnosed.

Vestibular Migraine Following Radiosurgery for Vestibular Schwannoma

Vestibular schwannoma (VS) is associated with dizziness and vertigo during all stages of treatment. This report describes a patient who presented with a one-year history of intermittent motion sickness, dizziness, headache, imbalance, and nausea. MRI showed a right-side VS in the cerebellopontine angle and internal auditory canal. The patient elected to undergo Gamma Knife radiosurgery for treatment. Within two to three months, she continued to experience recurring dizziness, vertigo, neck stiffness, and head pressure. She was referred for neurotology evaluation, which led to a diagnosis of vestibular migraine (VM). Her vestibular reflexes were intact. Subsequently, she was treated with diet modification and low-dose venlafaxine. She reported dramatically improved dizziness and vertigo symptoms at six-month follow-up. VM is a very common cause of dizziness that should always be included in the differential diagnosis, even in VS patients.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study

Background

Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs.

Methods

The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model.

Results

The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant.

Conclusions

The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.

Results and lessons learnt from a randomized controlled trial: prophylactic treatment of vestibular migraine with metoprolol (PROVEMIG)

Background

Vestibular migraine (VM) is the most frequent cause of recurrent spontaneous attacks of vertigo causally related to migraine. The objective of the Prophylactic treatment of vestibular migraine with metoprolol (PROVEMIG) trial was to demonstrate that metoprolol succinate is superior to placebo in the prevention of episodic vertigo- and migraine-related symptoms in patients with VM.

Methods

This phase III, two-arm, parallel-group, double-blind, randomized placebo-controlled trial was designed to be conducted at tertiary referral centres at neurology and ear, nose and throat departments of eight German university hospitals. The planned sample size was a total of 266 patients to be allocated. Adults aged 18 years or above diagnosed with probable or definitive VM according to the Neuhauser criteria 2001 were randomly assigned 1:1 to 6 months blinded metoprolol (maintenance dosage of 95 mg daily) or placebo. The primary efficacy outcome was the self-reported number of vertiginous attacks per 30 days documented by means of a paper-based daily symptom diary. The pre-specified time period of primary interest was defined as months 4 to 6. Secondary outcomes included the patient-reported number of migraine days and vertigo days, the Dizziness Handicap Inventory, and clinical assessments. Adverse events were reported throughout the whole 9-month study period.

Results

At the time of trial termination, no evidence for a difference in the incidence of vertiginous attacks between groups was detected. For the full analysis set, the incidence rate ratio was 0.983 (95% confidence interval (CI) 0.902–1.071) for metoprolol versus placebo. In both groups, there was a significant decline over time in the overall monthly vertigo attacks by a factor of 0.830 (95% CI 0.776–0.887). Results were consistent for all subjective and objective key measures of efficacy. The treatment was well tolerated with no unexpected safety findings.

Conclusions

After randomizing 130 patients PROVEMIG had to be discontinued because of poor participant accrual not related to the tolerability of the study medication or safety concerns; no treatment benefit of metoprolol over placebo could be established. Additional preparatory work is much needed in the development, psychometric evaluation and interpretation of clinically meaningful end points in trials on episodic syndromes like VM taking into consideration the complexity of this disease entity comprising two domains (vertigo- and headache-related disability).

Trial registration

EudraCT, 2009-013701-34. Prospectively registered on 8 April 2011.

Grey matter changes in patients with vestibular migraine

AIM

To identify structural changes in the brain regions of patients with vestibular migraine (VM) so as to better understand its pathophysiology.

MATERIAL AND METHODS

The differences in grey matter (GM) in patients with VM, patients with migraine without aura (MWoA), and healthy controls (HC) were investigated. Using a GE Signa 3 T magnetic resonance imaging (MRI) system, 3D structural images were acquired from 18 VM, 21 MWoA, and 21 age-, gender-, and education level-matched HC using a T1-weighted magnetization-prepared rapid acquisition gradient-echo (MPRAGE) sequence. The volumetric abnormalities of GM were estimated by voxel-based morphometry. Analysis of variance and Bonferroni multiple comparisons were applied.

RESULTS

Compared with HC, patients with VM had significantly increased GM volume of the right medial superior frontal gyrus (p=0.008) and the right angular gyrus (p=0.009). Compared to patients with MWoA, patients with VM also had significantly increased volume of the right medial superior frontal gyrus (p=0.001), the right angular gyrus (p=0.008), and the left middle frontal gyrus (p=0.001).

CONCLUSIONS

The GM volume of some brain regions of patients with VM is significantly larger than the other two groups. The increased GM volume in these brain regions in patients with VM may be related to self-adaptation of the nervous system, leading to an abnormal brain sensitization. Some of the brain regions with increased GM volume identified in this study were involved in assessment, integration, and expectations of pain and were strongly related to mood and anxiety.

Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review

Vestibular rehabilitation (VR) has been shown to be effective for many vestibular disorders. This review focuses on the current evidence on the effects of physical therapy in the management of vestibular symptoms in individuals with a vestibular migraine (VM). The individuals with a history of a migraine tend to have a high incidence of vestibular symptoms with some or all of their headaches. A total of six included studies investigated the effects of VR in the management of VM. The critical review form for quantitative studies was used to appraise quality assessment and risk of bias in the selected studies. Previous studies validated the use of VR in the treatment of vestibular symptoms for individuals with a VM to include improved headache and migraine-related disability in patients with a VM. From the current evidence, it is difficult to provide conclusive evidence regarding the efficacy of VR to minimize vestibular symptoms in patients with VM. Therefore, more randomized controlled studies are required to make firm evidence on the effect of VR in reducing vestibular symptoms in patients with VM. The future prospective, blinded, randomized controlled studies may help to isolate possible therapeutic effects of VR and other general effects.