Migraine-related vertigo: towards a distinctive entity

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.

Migraine: A disorder of metabolism?

The treatment and prevention of migraine within the last decade has become largely pharmacological. While there is little doubt that the advent of drugs (e.g. triptans) has helped many migraine sufferers to lead a normal life, there is still little knowledge with respect to the factors responsible for precipitating a migraine attack. Evidence from biochemical and behavioural studies from a number of disciplines is integrated to put forward the proposal that migraine is part of a cascade of events, which together act to protect the organism when confronted by a metabolic challenge.

Migraine in The Elderly: A Review

Although migraine is less prevalent in older than in younger age groups, the absolute increase in the number of subjects in older age groups may lead to an increase in the total number of migraine patients. Consequently, more elderly migraine patients may seek medical attention. In this review, the epidemiology and clinical aspects of migraine in the age group of ≥60 years are summarized, with special attention to comorbidity. The review will focus on treatment choices in elderly migraine patients. These must be based on knowledge of mechanisms of physiological and pathological ageing.

Modulation of Recognition Memory for Emotional Images by Vertical Vection

Our previous research showed that vertical vection could modulate human mood. We further examined this possibility by using memory recognition task of positive, negative and neutral emotional images with high and low arousal levels. Those images were remembered accidentally while the participants did visual dummy task, and later presented together with novel images during vertical vection-inducing or neutral visual stimuli. The results showed that downward vection facilitated the recognition of negative images and inhibited the recognition of positive ones. These modulations of incidental memory task provide an additional evidence for vection influence on cognitive and emotional processing, and also provide a new paradigm that can be used in future vection and embodied cognition research.

Migraine features in patients with Meniere's disease

OBJECTIVES/HYPOTHESIS

To better understand the features of migraine in Meniere's disease (MD).

STUDY DESIGN

Retrospective review of prospectively obtained surveys in an outpatient clinic of a tertiary medical center.

METHODS

Detailed questionnaires on headaches and dizziness were given to consecutive patients presenting with dizziness. The responses were verified by the clinician with the patient. The data, in addition to the clinical history and audiogram, were used to diagnose patients with migraine headaches and MD using criteria set by the International Headache Society (IHS) and the American Academy of Otolaryngology-Head and Neck Surgery, respectively. The prevalence of migraine-like symptoms in those patients with MD, who did not fit the diagnostic criteria for migraine, was evaluated.

RESULTS

Thirty-seven patients with definite MD were included. There was a predominance of females (female/male:26/11). Mean age of patients was 52 ± 14 years. Nineteen patients (51%) had migraine headaches. Fifteen patients fulfilled the criteria for definite vestibular migraine. Of those who did not fulfill the IHS migraine criteria, a majority had characteristics such as a family history of migraine, visual motion sensitivity, or lifelong motion sickness that were highly suggestive of a migraine disorder.

CONCLUSIONS

A majority of patients with MD have migraine headaches as defined by the IHS. Sensitivity to visual motion, light and sound, head motion, smells, weather changes, or medication was present in 95% of all patients with definite MD and 82% of non-IHS migraine MD patients. This may suggest that MD may be an atypical variant of migraine.

Vestibular Dysfunction in Patients With Chronic Pain or Underlying Neurologic Disorders

Context: Individuals with vestibular dysfunction are at increased risk for falling. In addition, vestibular dysfunction is associated with chronic pain, which could present a serious public health concern as approximately 43% of US adults have chronic pain.

Objective: To assess the incidence of vestibular dysfunction in patients receiving medication for chronic, noncancer pain or other underlying neurologic disorders and to determine associated follow-up therapeutic and diagnostic recommendations.

Methods: The authors conducted a retrospective medical record review of consecutive patients who were treated in their private neuroscience practice with medications for chronic pain or underlying neurologic disorders in 2011. All patients underwent a series of tests using videonystagmography for the assessment of vestibular function. Test results and recommendations for therapy and additional testing were obtained.

Results: Medical records of 124 patients (78 women, 46 men) were reviewed. Vestibular deficits were detected in 83 patients (66.9%). Patient ages ranged from 29 through 72 years, with a mean age of 50.7 years for women and 52.5 years for men. Physician-recommended therapy and follow-up testing were as follows: 32 patients (38.6%), neurologic examination and possible magnetic resonance (MR) imaging or computed tomography (CT) of the brain; 26 patients (31.3%), vestibular rehabilitation therapy only; 22 patients (26.5%), vestibular and related balance-function rehabilitation therapy, further neurologic examination, and possible MR imaging or CT; 2 patients (2.4%), balance-function rehabilitation therapy and specialized internal auditory canal high-magnification MR imaging or CT to assess for acoustic neuroma; and 1 patient (1.2%), specialized internal auditory canal high-magnification MR imaging or CT to evaluate for possible intracanalicular acoustic neuroma.

Conclusion: Patients being treated with medications for chronic, noncancer pain or other underlying neurologic disorders may have a higher-than-average incidence of vestibular dysfunction. Baseline assessment and monitoring of the vestibular apparatus may be indicated for these patients.

Vertigo as a migraine phenomenon

Migraine is a complex disorder with many different manifestations. There has been an increasing interest in the association of migraine and vertigo. Many different terms have been developed to describe this concept, the more popular being vestibular migraine, migrainous vertigo, and migraine-associated vertigo. The most commonly cited diagnostic criteria are that of Neuhauser though this has yet to be included in the International Classification of Headache Disorders (2nd edition). At this time, there is a lack of consensus regarding migraine-related vertigo and its pathomechanism. Regardless, a few randomized controlled prospective studies have been performed to evaluate the efficacy of various medications. Topiramate has been shown to be effective for migraine-related vertigo. At this time there is no specific treatment for migraine-related dizziness outside of conventional migraine management. The genetics have yet to be fully realized though an autosomal dominant familial migraine vertigo disorder has been identified.

A relationship between migraine and biliary tract disorders: findings in two Swedish samples of elderly twins

OBJECTIVES

To investigate whether there is a relationship between the clinical occurrence of migraine and biliary tract disorders (BTD) and to study whether there is a genetic influence on such an association.

MATERIALS AND METHODS

The near lifetime morbidity for migraine and BTD was examined in two Swedish twin-samples: OCTO-Twin (149 MZ and 202 DZ pairs; 234 men, 468 women; 80 years of age or older at inclusion), and the GENDER study (249 unlike-sex DZ-pairs; 70-80 years of age at inclusion). The diagnosis of BTD was established by perusal of medical records from the last twenty years. The diagnosis of migraine was based on iterated questionnaires and personal interviews.

RESULTS

The odds ratio (OR) of BTD among OCTO-Twin subjects suffering from migraine was 3.5 (1.9-6.7) in monozygotic pairs and 1.7 (1.0-2.9) in dizygotic pairs The corresponding figures among the GENDER unlike-sex DZ-pairs was 2.7 (1.6-4.5). Migraine was associated with female sex and waist circumference.

CONCLUSIONS

There is a relationship between the occurrence of migraine and BTD, also when controlling for the fact that both disorders are more frequent in women. The association appears to be partly attributable to genetic influences.

Different types of dizziness in patients with peripheral vestibular diseases--their prevalence and relation to migraine

CONCLUSIONS

Besides spontaneous attacks of vertigo or unsteadiness, other symptoms, i.e. drop attacks, lateropulsion, illusions that the room or body is tilted, 'walking on pillows' or 'stepping into a hole', occur without precipitating head movement in almost 50% of patients with peripheral vestibular dysfunctions. The sensation of static tilt was closely connected to migraine and Meniere's disease (MD).

OBJECTIVES

To record the prevalence of the different symptoms with respect to vestibular diagnosis and its relation to migraine.

METHODS

Data from 100 patients with MD, benign paroxysmal positional vertigo (BPPV), or unilateral peripheral vestibular impairment (UPVI) were analyzed with respect to vestibular diagnosis and migraine as a secondary diagnosis.

RESULTS

Spontaneous attacks of vertigo or unsteadiness occurred in 74% and 48% of patients, respectively. Vertigo was significantly more often reported in patients with MD and BPPV. In patients with BPPV, the duration of spontaneous vertigo was shorter than in patients with MD. The relative incidence of other symptoms were: unsteadiness, 48%; 'stepping into a hole', 46%; lateropulsion, 35%; 'walking on pillows', 21%; and drop attacks, 19%. Only the sensation of static tilt, which occurred in 8% of patients, was significantly correlated to MD or to migraine.

Migraine and vertigo: a marriage of convenience?

"Migraine associated vertigo" is emerging as a popular diagnosis for patients with recurrent vertigo. However, in view of our current understanding of both migraine and vertigo, "migraine associated vertigo," in contrast to basilar artery migraine, is neither clinically nor biologically plausible as a migraine variant.

Vestibular migraine

Vestibular migraine is a chameleon among the episodic vertigo syndromes because considerable variation characterizes its clinical manifestation. The attacks may last from seconds to days. About one-third of patients presents with monosymptomatic attacks of vertigo or dizziness without headache or other migrainous symptoms. During attacks most patients show spontaneous or positional nystagmus and in the attack-free interval minor ocular motor and vestibular deficits. Women are significantly more often affected than men. Symptoms may begin at any time in life, with the highest prevalence in young adults and between the ages of 60 and 70. Over the last 10 years vestibular migraine has evolved into a medical entity in dizziness units. It is the most common cause of spontaneous recurrent episodic vertigo and accounts for approximately 10% of patients with vertigo and dizziness. Its broad spectrum poses a diagnostic problem of how to rule out Menière's disease or vestibular paroxysmia. Vestibular migraine should be included in the International Headache Classification of Headache Disorders (ICHD) as a subcategory of migraine. It should, however, be kept separate and distinct from basilar-type migraine and benign paroxysmal vertigo of childhood. We prefer the term "vestibular migraine" to "migrainous vertigo," because the latter may also refer to various vestibular and non-vestibular symptoms. Antimigrainous medication to treat the single attack and to prevent recurring attacks appears to be effective, but the published evidence is weak. A randomized, double-blind, placebo-controlled study is required to evaluate medical treatment of this condition.

Migraine vestibulopathy in three families with idiopathic scoliosis: a case series

Introduction

We assessed clinical and etiological association between vestibular pathology and idiopathic scoliosis concerning seven members of three families with idiopathic scoliosis.

Case presentation

The families were referred to neurotology center for evaluation of balance problems. Patients were evaluated thorough anamnesis to relevant vestibular and audiological studies in addition to idiopathic scoliosis assessment. All evaluated scoliotic patients had clinical manifestations of vestibular dysfunctions and migrainous headache. All of the scoliotic patients (seven patients) in these three families were diagnosed as migraine vestibulopathy.

Conclusion

With the presentation of these three families, we discussed the probable role of the vestibular dysfunctions including migraine vestibulopathy in the development and progression of idiopathic scoliosis.

Association of benign recurrent vertigo and migraine in 208 patients

The aim of this study was to determine the association of benign recurrent vertigo (BRV) and migraine, using standardized questionnaire-based interview of 208 patients with BRV recruited through a University Neurotology clinic. Of 208 patients with BRV, 180 (87%) met the International Classification of Headache Disorders 2004 criteria for migraine: 112 migraine with aura (62%) and 68 without aura (38%). Twenty-eight (13%) did not meet criteria for migraine. Among patients with migraine, 70% experienced headache, one or more auras, photophobia, or auditory symptoms with some or all of their vertigo attacks, meeting the criteria for definite migrainous vertigo. Thirty per cent never experienced migraine symptoms concurrent with vertigo attacks. These met criteria for probable migrainous vertigo. Among patients without migraine, 21% experienced either photophobia or auditory symptoms with some or all of their vertigo attacks; 79% experienced only isolated vertigo. The age of onset and duration of vertigo attacks did not differ significantly between patients with (34 +/- 1.2 years) and patients without migraine (31 +/- 3.0 years). In patients with migraine, the age of onset of migraine headache preceded the onset of vertigo attacks by an average of 14 years and aura preceded vertigo by 8 years. The most frequent duration of vertigo attacks was between 1 h and 1 day. Benign recurrent vertigo is highly associated with migraine, but a high proportion of patients with BRV and migraine never have migraine symptoms during their vertigo attacks. Other features such as age of onset and duration of vertigo are similar between patients with or without migraine.

Migrainous Vertigo: Clinical, Oculographic and Posturographic Findings

Migrainous vertigo (MV) is accepted as a common cause of episodic vertigo. The peripheral or central vestibular localization of the deficit as well as the pathophysiology is unclear. This prospective study was designed to assess the clinical features of MV and to search for the localization of the vestibular pathology. Thirty-five patients with MV, 20 patients with migraine and 20 healthy volunteers were studied. Comprehensive neurotological tests were performed between attacks. None of the normal controls or the patients with migraine had ocular motor deficits or caloric test abnormalities. Three patients in the MV group showed saccadic pursuit (8.6±), in one of whom saccadic hypometria was also present. Caloric test results revealed unilateral caloric hypofunction in seven patients (20±). Static posturography results revealed increased sway velocity when the eyes were closed or the platform was distorted in patients with MV. These findings during the symptom-free period revealed that peripheral vestibular dysfunction was more common than a central deficit.

Migraine associated vertigo

The interrelations of migraine and vertigo are complex, eluding a simple localization either centrally or peripherally. Spontaneous episodic vertigo, benign paroxysmal positional vertigo, and Meniere's disease all occur more frequently in patients with migraine than in those without. Family studies support a hereditary predisposition to migraine associated vertigo. In this review, we discuss definitions, epidemiology, associated syndromes, neurootological abnormalities, genetics and treatment for patients with migraine and vertigo.

Vertigo, dizziness and imbalance in the elderly

Objective:

The aim of this retrospective analysis was to evaluate the diagnosis of vertigo, dizziness and imbalance in elderly patients in two tertiary neurotology clinics.

Design and setting:

Six hundred and seventy-seven patients aged over 65 years were assessed by the same senior author, and 601 patients were enrolled in the study.

Results:

The most frequent diagnoses were benign paroxysmal positional vertigo (42.43 per cent), idiopathic vestibulopathy (20.29 per cent), migraine vestibulopathy (13.15 per cent), Ménière's disease (12.47 per cent) and acute vestibular attack (6.49 per cent).

Conclusion and significance:

This retrospective study showed that 93.5 per cent of the elderly patients studied had been diagnosed with peripheral vertigo. The majority of patients had been classified as having benign paroxysmal positional vertigo, idiopathic vestibulopathy or migraine vestibulopathy.

Ocular motor measures in migraine with and without aura

The purpose of this study was to examine basic ocular motor function in individuals with migraine. We used an infrared eye-tracking system to measure horizontal smooth pursuit to a sinusoidal target, saccades to horizontal target displacements of 5-20 degrees , and the stability of fixation in 19 migraine without aura (MoA), 19 migraine with aura (MA) and 19 headache-free control (C) subjects. Eye movement measurements were made at two target displacement rates and against both homogeneous grey and patterned backgrounds. We found no statistically significant differences between migraine and control subjects in any of the eye movement parameters measured, but did find highly significant effects of both target speed and background pattern in all groups. Our results do not provide support for subclinical cerebellar impairment in migraineurs, and do provide evidence that previously described visual abnormalities in migraine are not artefacts of abnormal fixation or eye movements.