Familial clustering of migraine, episodic vertigo, and Ménière's disease

Vestibular migraine as a mimic of benign paroxysmal positioning vertigo and Meniere's disease

BACKGROUND

Vestibular migraine (VM) is a common cause of recurrent spontaneous and positional dizziness of varying durations. Short episodes of VM lasting seconds to minutes, triggered by changes in head position can resemble those of benign paroxysmal positioning vertigo (BPPV), while episodes lasting minutes to hours can mimic those of Meniere's disease (MD).

OBJECTIVE

We aimed to compare symptoms and vestibular test results in patients with VM, BPPV and MD, where VM was categorized by episode duration.

METHODS

We compared vestibular, aural and migraine symptoms, as well as cervical and ocular vestibular evoked myogenic potentials and 3D video head impulse tests, in 108 patients: 24 with BPPV, 33 with VM episodes of short duration (<10 min), 29 with VM of medium duration (≥10 min) and 22 with MD.

RESULTS

We found significant overlap in the symptoms of all patient groups, and no significant differences between patients with short and medium VM. Abnormal test results occurred infrequently in all groups.

CONCLUSIONS

Our results confirm significant symptom overlap between BPPV or MD and VM, and suggest that VM mimics other conditions when the episode duration matches the differential diagnosis, rather than because patients with different durations of vertigo have different symptoms.

Visual vertigo and motion sickness is different between persistent postural-perceptual dizziness and vestibular migraine

INTRODUCTION

Persistent postural-perceptual dizziness (PPPD) and vestibular migraine (VM) share symptoms of visual vertigo and motion sickness that can be confusing for clinicians to distinguish. We compare the severity of these symptoms and dynamic subjective visual vertical (dSVV) in these two common vestibular conditions.

METHOD

Twenty-nine patients with PPPD, 37 with VM, and 29 controls were surveyed for subjective symptoms using the visual vertigo analogue scale (VVAS) and motion sickness susceptibility questionnaire during childhood (MSA) and the past 10 years (MSB). dSVV is a measure of visual dependence measures perception of verticality against a rotating background (5 deg./s).

RESULTS

VVAS revealed contextual differences for dizziness between those with PPPD and VM. Ratings of visual vertigo were most severe in PPPD, less in VM, and mild in controls (VVAS PPPD 27.1, VM 11.2, control 4.6, p < 0.001). MSA was more severe in VM than in PPPD or control (12.8 vs 7.6 vs 8.5, p = 0.01). MSB was more severe in VM than controls (MSB score 12.9 VS 8.1 p = 0.009) but was not different than PPPD (MSB score 10.0, p = 0.10). dSVV alignment was similar among the three groups (p = 0.83). Both VM and PPPD groups had greater simulator sickness than controls after completing the dSVV.

CONCLUSIONS

Patients with PPPD report more visual vertigo than those with VM, but a history of motion sickness as a child is more common in VM. Additionally, the environmental context that induces visual vertigo is different between PPPD and VM.

Auditory Manifestations of Vestibular Migraine

Objectives

To investigate the auditory features of patients with vestibular migraine (VM) and to analyze the possible relevant factors of hearing loss.

Methods

A total of 166 patients with VM were enrolled. Demographic variables, age of onset, disease course, distribution of vestibular attacks, characteristics of hearing loss, and the coexistence of related disorders, such as visual aura, familial history, motion sickness, nausea, headache, photophobia, otalgia, tinnitus, aural fullness, and phonophobia, were analyzed and compared.

Results

Patients with VM can manifest otalgia (8.4%), tinnitus (51.8%), aural fullness (41%), and phonophobia (31.9%). Of 166 patients, the prevalence of VMw was 21.1% (n = 35). Patients with VMw mainly manifested mild and easily reversible low-frequency hearing loss. The proportions of tinnitus and aural fullness were significantly larger in patients with VMw than that in patients with VMo (P < 0.05). The duration of vestibular symptoms was significantly shorter in patients with VMw (P < 0.05). However, the age of onset, disease course, gender, frequency of vestibular attacks, the coexistence of visual aura, familial history, motion sickness, nausea, headache, photophobia, otalgia, and phonophobia had no significant difference between the two groups.

Conclusion

Auditory symptoms were common in patients with VM. The hearing loss of VM was characterized by a mild and easily reversible low-frequency hearing loss, accompanied by higher proportions of tinnitus and aural fullness, and a shorter duration of vestibular symptoms compared with patients with VMo.

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 Predictive Model of Bilateral Sensorineural Hearing Loss in Meniere Disease Using Clinical Data

OBJECTIVES

Meniere disease (MD) is defined by a clinical syndrome of recurrent attacks of spontaneous vertigo associated with tinnitus, aural fullness, and sensorineural hearing loss (SNHL). Most patients have unilateral SNHL, but some of them will develop contralateral SNHL during the course of the disease. Several studies have reported a frequency of 2 to 73% SNHL in the second ear, according to the duration of disease and the period of follow-up. We hypothesize that unilateral and bilateral MD are different conditions, the first would initially involve the apical turn of the cochlea, while bilateral MD would affect the entire length of the cochlea. The aim of the study is to search for clinical predictors of bilateral SNHL in MD to build a predictive model of bilateral involvement.

DESIGN

A retrospective, longitudinal study including two cohorts with a total of 400 patients with definite MD was carried out. The inception cohort consisted of 150 patients with MD and the validation cohort included 250 cases. All of the cases were diagnosed of unilateral MD according to their hearing loss thresholds. The following variables were assessed as predictors of bilateral SNHL for the two cohorts: sex, age of onset, familiar history of MD, migraine and high-frequency hearing loss (HFHL, defined if hearing threshold >20 dB in two or more consecutive frequencies from 2 to 8 KHz). A descriptive analysis was carried out according to the presence of HFHL in the first audiogram for the main variables. By using multiple logistic regression, we built-up several predictive models for the inception cohort and validated it with the replication cohort and merged dataset.

RESULTS

Twenty-three (19.3%) and 78 (41%) of patients with HFHL developed contralateral SNHL during the follow-up, in the inception and validation cohorts, respectively. In the inception cohort, the best predictive model included HFHL in the first audiogram (OR = 6.985, p = 0.063) and the absence of migraine (OR = 0.215, p = 0.144) as clinical predictors for bilateral SNHL [area under the curve (AUC) = 0.641, p = 0.002]. The model was validated in the second cohort (AUC = 0.621, p < 0.001). Finally, we merged both datasets to improve the precision of the model including HFHL in the first audiogram (OR = 3.168, p = 0.001), migraine (OR = 0.482, p = 0.036) and age of onset >35 years old (OR = 2.422, p = 0.006) as clinical predictors (AUC = 0.639, p < 0.001).

CONCLUSIONS

A predictive model including the age of onset, HFHL in the first audiogram and migraine can help to assess the risk of bilateral SNHL in MD. This model may have significant implications for clinical management of patients with MD.

Machine Learning Techniques for Differential Diagnosis of Vertigo and Dizziness: A Review

Vertigo is a sensation of movement that results from disorders of the inner ear balance organs and their central connections, with aetiologies that are often benign and sometimes serious. An individual who develops vertigo can be effectively treated only after a correct diagnosis of the underlying vestibular disorder is reached. Recent advances in artificial intelligence promise novel strategies for the diagnosis and treatment of patients with this common symptom. Human analysts may experience difficulties manually extracting patterns from large clinical datasets. Machine learning techniques can be used to visualize, understand, and classify clinical data to create a computerized, faster, and more accurate evaluation of vertiginous disorders. Practitioners can also use them as a teaching tool to gain knowledge and valuable insights from medical data. This paper provides a review of the literatures from 1999 to 2021 using various feature extraction and machine learning techniques to diagnose vertigo disorders. This paper aims to provide a better understanding of the work done thus far and to provide future directions for research into the use of machine learning in vertigo diagnosis.

Skull Vibration-Induced Nystagmus Test (SVINT) in Vestibular Migraine and Menière's Disease

BACKGROUND

Vestibular migraine (VM) and Menière's disease (MD) are the two most frequent episodic vertigo apart from Benign Paroxysmal Positional Vertigo (BPPV) differential diagnosis for them may be troublesome in the early stages. SVINT is a newly proposed vestibular test, which demonstrated to be fast and reliable in diagnoses above all of peripheral vestibular deficits.

METHODS

We retrieved clinical data from two groups of subjects (200 VM and 605 MD), enrolled between 2010 and 2020. Among others, these subjects were included when performing a SVINT. The purpose of the study is to assess if SVINT can be useful to differentiate the two episodic disorders.

RESULTS

59.2% of MD subjects presented as positive with SVINT while only 6% did so with VM; among other tests, only video HIT demonstrated a different frequency in the two groups (13.1% and 0.5%, respectively), but the low sensitivity in these subjects makes the test unaffordable for diagnostic purposes.

CONCLUSIONS

Since SVINT demonstrated to be positive in a peripheral vestibular deficit in previous works, we think that our data are consistent with the hypothesis that, in the pathophysiology of VM attacks, the central vestibular pathways are mainly involved.

A Family with a High Incidence of Migraine and Vestibular Migraine and a Case of Menière's Disease

Vestibular migraine (VM) and Menière's disease (MD) are common neurotological disorders causing episodic vertigo. Sometimes, VM is accompanied by cochlear symptoms suggestive for MD. Therefore, in those cases, the differential diagnosis between the two disorders can be difficult. Moreover, a comorbidity with migraine in MD patients is widely reported, up to the hypothesis of a possible MD-VM overlapping syndrome. In this brief case report, we consider the clinical history of a family presenting high incidence of subjects fulfilling the diagnostic criteria of VM and single case fulfilling criteria for definite MD. The relationship between VM and MD is still under debate; anyway, it can be speculated that commonly shared genetic mutations could play a role as predisposing factors in both disorders. A congenital nystagmus in the family was present too, but its correlation with the other conditions is still not clear. Future goal of our work will be to assess genetics in this family.

Burden of Rare Variants in the OTOG Gene in Familial Meniere's Disease

OBJECTIVES

Meniere's disease (MD) is a rare inner ear disorder characterized by sensorineural hearing loss, episodic vertigo, and tinnitus. Familial MD has been reported in 6 to 9% of sporadic cases, and few genes including FAM136A, DTNA, PRKCB, SEMA3D, and DPT have been involved in single families, suggesting genetic heterogeneity. In this study, the authors recruited 46 families with MD to search for relevant candidate genes for hearing loss in familial MD.

DESIGN

Exome sequencing data from MD patients were analyzed to search for rare variants in hearing loss genes in a case-control study. A total of 109 patients with MD (73 familial cases and 36 early-onset sporadic patients) diagnosed according to the diagnostic criteria defined by the Barany Society were recruited in 11 hospitals. The allelic frequencies of rare variants in hearing loss genes were calculated in individuals with familial MD. A single rare variant analysis and a gene burden analysis (GBA) were conducted in the dataset selecting 1 patient from each family. Allelic frequencies from European and Spanish reference datasets were used as controls.

RESULTS

A total of 5136 single-nucleotide variants in hearing loss genes were considered for single rare variant analysis in familial MD cases, but only 1 heterozygous likely pathogenic variant in the OTOG gene (rs552304627) was found in 2 unrelated families. The gene burden analysis found an enrichment of rare missense variants in the OTOG gene in familial MD. So, 15 of 46 families (33%) showed at least 1 rare missense variant in the OTOG gene, suggesting a key role in familial MD.

CONCLUSIONS

The authors found an enrichment of multiplex rare missense variants in the OTOG gene in familial MD. This finding supports OTOG as a relevant gene in familial MD and set the groundwork for genetic testing in MD.

Do we need to reconsider the classification of vestibular migraine?

Introduction: Vestibular migraine (VM) is a complex disease characterized by recurrent episodes of migraine associated with vertigo attacks that are observed in 1-3% of the general population. Given its high prevalence and the impact on the health system, it is important to characterize these patients, in order to offer an accurate diagnosis and a proper treatment. As the diagnosis of VM is based on clinical features, the study of potential biomarkers has gained more interest in the last years, to improve the precision in the diagnosis of this disease. The aim of this review is to summarize the main tests available for the diagnosis of VM, including the accuracy of biomarkers for the diagnosis of VM.Areas covered: This review summarizes the main information on VM, including all diagnosis records published in the field in the last 10 years, and focusing on candidate biomarkers for the diagnosis of VM patients.Expert opinion: There is a limited knowledge in the pathophysiology of VM. The search of biomarkers for diagnosis of VM is needed to improve the precision in the diagnosis promoting clinical and translational research. The potential reclassification of VM will depend upon the discovery and validation of these biomarkers.

Vertigo without cochlear symptoms: vestibular migraine or Menière disease?

BACKGROUND

Menière's disease (MD) is an inner ear disorder due to raised endolymphatic pressure (hydrops), characterized by cochlear symptoms associated with episodic vertigo. In delayed hydrops, vertigo attacks begin long after the onset of a hearing loss. Few were published on MD in which the onset of vertigo precedes cochlear symptoms by several months. Vestibular migraine (VM) is also a cause of episodic vertigo and an association between migraine and MD was proposed. Purpose of our retrospective work was to assess clinical features associated with MD in which vertigo precedes by months cochlear symptoms.

METHODS

Our sample was composed by 28 subjects reporting episodic vertigo accompanied by migrainous headache or photo-phonophobia, without cochlear symptoms at onset; during follow-up, all patients developed cochlear symptoms leading to a diagnosis of MD. Results of bedside examination were compared with those of 48 VM subjects with diagnosis of VM confirmed in the follow-up. All subjects performed a bedside examination, including head-shaking, positional, and skull vibration test (SVIN).

RESULTS

SVIN was more frequent in MD, while positive positional test in VM. In the entire group of 72 subjects, migrainous headache during vertigo and positive positional test were correlated with a final diagnosis of VM.

CONCLUSIONS

Our data are not inconsistent with the hypothesis that in patients reporting only photo-phonophobia during vertigo attacks and with a positive SVIN, the clinical manifestations may be predictive for evolution toward a MD, while migrainous headache and positive positional tests more frequently are correlated to VM.

Systematic Review of Prevalence Studies and Familial Aggregation in Vestibular Migraine

Background: Vestibular migraine (VM) is complex disorder consisting of episodes of migraine and vertigo with an estimated prevalence of 1–3%. As migraine, it is considered that VM has genetic predisposition; however, evidence to support a genetic contribution has not been critically appraised.

Objective: The aim of this systematic review is to assess available evidence in scientific publications to determine the role of inheritance in VM.

Methods: After performing the quality assessment of the retrieved records, 31 studies were included (24 epidemiological reports and 7 genetic association studies in families or case-control in candidate genes). We gathered data about prevalence of VM in different populations and in families, and also about the genetic findings reported. In addition, other variables were considered to assess the heritability of VM, such as the ancestry, the age of onset or the familial history of vertigo and migraine.

Results: The estimated prevalence of VM was different between black (3.13%), white (2.64%) and Asian (1.07%) ethnicities. The reported prevalence of VM in migraine patients is higher in European countries (21%) than in Asian countries (10%). Moreover, the prevalence of the migraine-vertigo association in families is 4–10 times higher than the prevalence reported in the general population (sibling recurrence risk ratio λ_s = 4.31–10.42). We also found that the age of onset is lower in patients with simultaneous onset of symptoms and in those who have familial history for migraine and/or vertigo, suggesting anticipation. Although some genetic studies have reported few allelic variants associated to MV, replication studies are needed to validate these results.

Conclusions: The available evidence to support heritability in VM is limited. Variability in prevalence depending on ethnicity and geographic location suggests a combined genetic and environmental contribution to VM. However, the familial aggregation observed in VM support genetic and shared familial environmental effects that remarks the necessity of twins and adoptees-based epidemiological studies to estimate its heritability.

A hypothetical proposal for association between migraine and Meniere's disease

Meniere's disease (MD) is a chronic condition affecting the inner ear whose precise etiology is currently unknown. We propose the hypothesis that MD is a migraine-related phenomenon which may have implications for future treatment options for both diseases. The association between MD and migraine is both an epidemiological and a mechanistic one, with up to 51% of individuals with MD experiencing migraine compared to 12% in the general population. The presence of endolymphatic hydrops in those with MD may be the factor that unites the two conditions, as hydropic inner ears have an impaired ability to maintain homeostasis. Migraine headaches are theorized to cause aura and symptoms via spreading cortical depression that ultimately results in substance P release, alterations in blood flow, and neurogenic inflammation. Chronically hydropic inner ears are less able to auto-regulate against the changes induced by active migraine attacks and may ultimately manifest as MD. This same vulnerability to derangements in homeostasis may also explain the common triggering factors of both MD attacks and migraine headaches, including stress, weather, and diet. Similarly, it may explain the efficacy of common treatments for both diseases: current migraine treatments such as anti-hypertensives and anti-convulsants have shown promise in managing MD. Though the etiology of both MD and migraine is likely multifactorial, further exploration of the association between the two conditions may illuminate how to best manage them in the future. MD is likely a manifestation of cochleovestibular migraine, which occurs as a result of migraine related changes in both the cochlea and vestibule.

Vestibular migraine: An update on current understanding and future directions

BACKGROUND

Vestibular migraine is among the most common causes of recurrent vertigo in the general population. Despite its prevalence and high impact on healthcare cost and utilization, it has remained an under-recognized condition with largely unknown pathophysiology. In the present article, we aim to provide an overview of the current understanding of vestibular migraine.

METHODS

We undertook a narrative literature review on the epidemiology, presentations, clinical and laboratory findings, pathophysiology, and treatments of vestibular migraine.

RESULTS

Currently, the diagnosis of vestibular migraine relies solely on clinical symptoms since clinical tests of vestibular function are typically normal, or difficult to interpret based on inconsistent results reported in earlier studies. The challenges related to diagnosis of vestibular migraine lie in its relatively broad spectrum of manifestations, the absence of typical migraine headaches with vestibular symptoms, and its very recent definition as a distinct entity. Here, we highlight these challenges, discuss common vestibular symptoms and clinical presentations in vestibular migraine, and review the current aspects of its clinical diagnosis and evaluation. The concepts related to the pathophysiology and treatment of vestibular migraine are also discussed.

CONCLUSION

Vestibular migraine is still underdiagnosed clinically. Future studies are needed to address the pathophysiological mechanisms and investigate effective treatment regimens.

[Diagnostic criteria for Menière's disease according to the Classification Committee of the Bárány Society]

This paper presents diagnostic criteria for Menière's disease jointly formulated by the Classification Committee of the Bárány Society, The Japan Society for Equilibrium Research, the European Academy of Otology and Neurotology (EAONO), the Equilibrium Committee of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) and the Korean Balance Society. The classification includes two categories: definite Menière's disease and probable Menière's disease. The diagnosis of definite Menière's disease is based on clinical criteria and requires the observation of an episodic vertigo syndrome associated with low- to medium-frequency sensorineural hearing loss and fluctuating aural symptoms (hearing, tinnitus and/or fullness) in the affected ear. Duration of vertigo episodes is limited to a period between 20 min and 12 h. Probable Menière's disease is a broader concept defined by episodic vestibular symptoms (vertigo or dizziness) associated with fluctuating aural symptoms occurring in a period from 20 min to 24 h.

Recurrent spontaneous vertigo with interictal headshaking nystagmus

Objective

To define a disorder characterized by recurrent spontaneous vertigo (RSV) of unknown etiology and interictal headshaking nystagmus (HSN).

Methods

We characterized HSN in 35 patients with RSV-HSN compared to that recorded in randomly selected patients with compensated vestibular neuritis (VN), vestibular migraine (VM), and Ménière disease (MD).

Results

The estimated time constant (TC) of the primary phase of HSN was 12 seconds (95% confidence interval [CI] 12–13) in patients with RSV-HSN, which was larger than those in patients with VN (5 seconds, 95% CI 4–5), VM (5 seconds, 95% CI 5–6), or MD (6 seconds, 95% CI 5–6). TCs of the horizontal vestibulo-ocular reflex were also larger during the rotatory chair test in patients with RSV-HSN. Among the 35 patients with RSV-HSN, 7 showed vigorous long-lasting HSN with a peak slow-phase velocity >50.0°/s. In 5 patients (5 of 7, 71%) with vigorous HSN, HSN could have been induced even with headshaking for only 2 to 5 seconds. Long-term prognosis was favorable, with a resolution or improvement of the symptoms in more than half of the patients during the median follow-up of 12 (range 2–58) years from symptom onset. None developed VM, MD, or cerebellar dysfunction during the follow-up.

Conclusion

The clinical features and characteristics of HSN in our patients indicate a hyperactive and asymmetric velocity-storage mechanism that gives rise to intermittent attacks of spontaneous vertigo probably when marginal compensation of underlying pathology is disrupted by endogenous or exogenous factors.

Newly Diagnosed Meniere's Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine

OBJECTIVE

To describe the course of Meniere's disease with noninvasive treatment during the first few years after initial diagnosis.

METHODS

A retrospective review of consecutive patients with newly diagnosed definite Meniere's disease between 2013 and 2016 and a minimum follow-up of 1 year. Patients received a written plan for low sodium, water therapy, and treatment with a diuretic and/or betahistine. Subjects were screened and treated for vestibular migraine as needed. Vertigo control and hearing status at most recent follow-up were assessed.

RESULTS

Forty-four subjects had an average follow up of 24.3 months. Thirty-four percent had Meniere's disease and vestibular migraine, and 84% had unilateral Meniere's disease. Seventy-five percent had vertigo well controlled at most recent follow-up, with only noninvasive treatments. Age, gender, body mass index, presence of vestibular migraine, bilateral disease, and duration of follow-up did not predict noninvasive treatment failure. Worse hearing threshold at 250 Hz and lower pure tone average (PTA) at the time of diagnosis did predict failure. Fifty-two percent of ears had improved PTA at most recent visit, 20% had no change, and 28% were worse Conclusions: Encountering excellent vertigo control and stable hearing after a new diagnosis of Meniere's disease is possible with noninvasive treatments. Worse hearing status at diagnosis predicted treatment failure.

Abnormal Cervical Vestibular-Evoked Myogenic Potentials Predict Evolution of Isolated Recurrent Vertigo into Meniere's Disease

Introduction

Vestibular-evoked myogenic potentials (VEMPs) can be abnormal in patients with idiopathic recurrent spontaneous vertigo. We aimed to determine whether abnormal cervical vestibular-evoked myogenic potentials (cVEMPs) can predict evolution of isolated recurrent vertigo into Meniere’s disease (MD).

Methods

We had followed up 146 patients with isolated recurrent vertigo and an evaluation of cVEMPs for 0–142 months [median = 6, interquartile range (IQR) = 0–29] at the Dizziness Clinic of Seoul National University Bundang Hospital from June 2003 to May 2014. We defined the variables associated with a progression into MD and calculated cumulative progression rates.

Results

Among the 94 patients with recurrent vertigo and abnormal cVEMPs, 18 (18/94, 19%) showed an evolution into MD while only 2 of the 50 (4%) patients with normal cVEMPs evolved into MD during the follow-up (p = 0.01). The interval between onset of vertigo and development of cochlear symptoms ranged from 1 month to 13.6 years (median = 3 years, IQR = 0.5–4.5 years). Overall, pure tone audiometry (PTA) threshold at 0.25 kHz [hazard ratio (HR) = 1.1, 95% confidence interval (CI) = 1.0–1.2] and abnormalities of cVEMPs (HR = 5.6, 95% CI = 1.3–25.5) were found to be significantly associated with a later conversion into MD. The cumulative progression rate was 12% (95% CI = 5–18) at 1 year, 18% (8–26) at 2 years, and 22% (11–32) at 3 years.

Conclusion

Abnormal cVEMPs may be an indicator for evolution of isolated recurrent vertigo into MD. Patients with isolated recurrent vertigo may be better managed conforming to MD when cVEMPs are abnormal.

Magnetic resonance imaging of intratympanic gadolinium helps differentiate vestibular migraine from Ménière disease

OBJECTIVES/HYPOTHESIS

To study the differential diagnosis of vestibular migraine (VM) and Ménière disease (MD) by using magnetic resonance imaging (MRI) of intratympanic gadolinium.

STUDY DESIGN

Prospective cohort study.

METHODS

Definite MD patients (n = 30) and definite or probable VM patients (n = 30) were included, and the two groups were age and sex matched. Three-dimensional real inversion recovery (3D-real-IR) MRI was performed 24 hours after bilateral intratympanic gadolinium to assess the presence and degree of endolymphatic hydrops (EH). Response rates, amplitudes, latency, and response threshold of cervical and ocular vestibular evoked myogenic potentials (c/oVEMPs) were tested by using air-conducted sound. Pure tone audiometry was used to evaluate the level of hearing loss.

RESULTS

Different degrees of EH were observed in the cochlea and vestibule in the affected ears of MD patients, but only suspicious cochlear hydrops and no vestibular hydrops was noted in the VM patients. The correlation between the degree of EH and low-frequency hearing loss was statistically significant. Only the response threshold for c/oVEMP differentiated the MD-affected side from VM. The latency and amplitude for c/oVEMP showed no significant difference between groups.

CONCLUSIONS

Characteristic pathological changes of MD include EH in the inner ear, and 3D-real-IR MRI helps differentiate VM from MD. VM and MD behaved similarly in vestibular dysfunction and their transduction pathway, but MD appeared to be more severe than VM. An association in their pathophysiology may play a part in these responses.

LEVEL OF EVIDENCE

4 Laryngoscope, 127:2382-2388, 2017.

The Intimate Relationship between Vestibular Migraine and Meniere Disease: A Review of Pathogenesis and Presentation

Vestibular migraine (VM) has only recently been recognized as a distinct disease entity. One reason is that its symptoms overlap greatly with those of other vestibular disorders, especially Meniere disease (MD). The pathophysiology of neither VM nor MD is entirely elucidated. However, there are many theories linking migraine to both disorders. We reviewed the current understanding of migraine, VM, and MD and described how VM and MD are similar or different from each other in terms of pathophysiology and presentation, including hypotheses that the two share a common etiology and/or are variants of the same disease.

Comparison of caloric and head-impulse tests during the attacks of Meniere's disease

OBJECTIVES/HYPOTHESIS

To aid in diagnosis of Meniere's disease (MD) during the attacks using caloric and head-impulse tests (HITs).

STUDY DESIGN

Retrospective case series review.

METHODS

We analyzed the results of bithermal caloric and HITs during the attacks in 16 patients with MD. Quantitative analyses of HITs were conducted using a magnetic search coil technique.

RESULTS

In unilateral MD (14 patients, 42 semicircular canals), the head impulse gain of the vestibulo-ocular reflex (VOR) was either normal (28 of 42, 67%), decreased (8 of 42, 19%), or increased (6 of 42, 14%) for each semicircular canal in the affected ear. Likewise, the head impulse VOR gain was either normal (29 of 42, 69%), increased (11 of 42, 26%), or decreased (2 of 42, 5%) in the intact ear. The VOR gain for the horizontal canal was significantly lower on the affected side (P = 0.013). However, the VOR gains for the anterior and posterior canals did not differ between the sides (P = 0.270, P = 0.282). In bilateral MD (two patients, 12 semicircular canals), the VOR gain was either decreased (6 of 12, 50%) or normal (6 of 12, 50%) in either ear. In contrast, the caloric responses were usually decreased in the affected ear (7 of 11, 64%, including one with bilateral MD).

CONCLUSION

During the attacks of MD, HITs showed varied results between the ears and among the canals, although the caloric responses were usually decreased in the involved ear. These dissociations suggest a frequency-dependent impairment of canal function or mechanical property of the endolymphatic hydrops during the attacks of MD.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:702-708, 2017.

Meniere's disease

Meniere's disease (MD) is a disorder of the inner ear that causes vertigo attacks, fluctuating hearing loss, tinnitus and aural fullness. The aetiology of MD is multifactorial. A characteristic sign of MD is endolymphatic hydrops (EH), a disorder in which excessive endolymph accumulates in the inner ear and causes damage to the ganglion cells. In most patients, the clinical symptoms of MD present after considerable accumulation of endolymph has occurred. However, some patients develop symptoms in the early stages of EH. The reason for the variability in the symptomatology is unknown and the relationship between EH and the clinical symptoms of MD requires further study. The diagnosis of MD is based on clinical symptoms but can be complemented with functional inner ear tests, including audiometry, vestibular-evoked myogenic potential testing, caloric testing, electrocochleography or head impulse tests. MRI has been optimized to directly visualize EH in the cochlea, vestibule and semicircular canals, and its use is shifting from the research setting to the clinic. The management of MD is mainly aimed at the relief of acute attacks of vertigo and the prevention of recurrent attacks. Therapeutic options are based on empirical evidence and include the management of risk factors and a conservative approach as the first line of treatment. When medical treatment is unable to suppress vertigo attacks, intratympanic gentamicin therapy or endolymphatic sac decompression surgery is usually considered. This Primer covers the pathophysiology, symptomatology, diagnosis, management, quality of life and prevention of MD.

Genetics of vestibular disorders: pathophysiological insights

The two most common vestibular disorders are motion sickness and vestibular migraine, affecting 30 and 1–2 % of the population respectively. Both are related to migraine and show a familial trend. Bilateral vestibular hypofunction is a rare condition, and some of patients also present cerebellar ataxia and neuropathy. We present recent advances in the genetics of vestibular disorders with familial aggregation. The clinical heterogeneity observed in different relatives of the same families suggests a variable penetrance and the interaction of several genes in each family. Some Mendelian sensorineural hearing loss also exhibits vestibular dysfunction, including DFNA9, DFNA11, DFNA15 and DFNA28. However, the most relevant finding during the past years is the familial clustering observed in Meniere’s disease. By using whole exome sequencing and combining bioinformatics tools, novel variants in DTNA and FAM136A genes have been identified in familial Meniere’s disease, and this genomic strategy will facilitate the discovery of the genetic basis of familial vestibular disorders.

Vestibular migraine: the most frequent entity of episodic vertigo

Vestibular migraine (VM) is the most common cause of episodic vertigo in adults as well as in children. The diagnostic criteria of the consensus document of the International Bárány Society for Neuro-Otology and the International Headache Society (2012) combine the typical signs and symptoms of migraine with the vestibular symptoms lasting 5 min to 72 h and exclusion criteria. Although VM accounts for 7% of patients seen in dizziness clinics and 9% of patients seen in headache clinics it is still underdiagnosed. This review provides an actual overview on the pathophysiology, the clinical characteristics to establish the diagnosis, the differential diagnosis, and the treatment of VM.

Vestibular migraine

During the last decades a new vestibular syndrome has emerged that is now termed vestibular migraine (VM). The main body of evidence for VM is provided by epidemiologic data demonstrating a strong association between migraine and vestibular symptoms. Today, VM is recognized as one of the most common causes of episodic vertigo. The clinical presentation of VM is heterogeneous in terms of vestibular symptoms, duration of episodes, and association with migrainous accompaniments. Similar to migraine, there is no clinical or laboratory confirmation for VM and the diagnosis relies on the history and the exclusion of other disorders. Recently, diagnostic criteria for VM have been elaborated jointly by the International Headache Society and the Bárány Society. Clinical examination of patients with acute VM has clarified that the vast majority of patients with VM suffer from central vestibular dysfunction. Findings in the interval may yield mild signs of damage to both the central vestibular and ocular motor system and to the inner ear. These interictal clinical signs are not specific to VM but can be also observed in migraineurs without a history of vestibular symptoms. How migraine affects the vestibular system is still a matter of speculation. In the absence of high-quality therapeutic trials, treatment is targeted at the underlying migraine.

The epidemiology of dizziness and vertigo

This chapter gives an overview of the epidemiology of dizziness, vertigo, and imbalance, and of specific vestibular disorders. In the last decade, population-based epidemiologic studies have complemented previous publications from specialized settings and provided evidence for the high burden of dizziness and vertigo in the community. Dizziness (including vertigo) affects about 15% to over 20% of adults yearly in large population-based studies. Vestibular vertigo accounts for about a quarter of dizziness complaints and has a 12-month prevalence of 5% and an annual incidence of 1.4%. Its prevalence rises with age and is about two to three times higher in women than in men. Imbalance has been increasingly studied as a highly prevalent complaint particularly affecting healthy aging. Studies have documented the high prevalence of benign paroxysmal positional vertigo (BPPV) and vestibular migraine (VM), as well as of comorbid anxiety at the population level. BPPV and VM are largely underdiagnosed, while Menière's disease, which is about 10 times less frequent than BPPV, appears to be overdiagnosed. Risk factor research is only at its beginning, but has provided some interesting observations, such as the consistent association of vertigo and migraine, which has greatly contributed to the recognition of VM as a distinct vestibular syndrome.

Vestibular migraine

Vestibular migraine is now considered a distinct diagnostic entity by both the Barany Society and the International Headache Society. The recognition of vestibular migraine as a diagnostic entity required decades and was presaged by several reports indicating that a large proportion of patients with migraine headaches have vestibular symptoms and that a large proportion of patients with undiagnosed episodic vestibular symptoms have migraine headache. Despite the availability of diagnostic criteria for vestibular migraine, challenges to diagnosis include variability in terms of the character of dizziness, the presence or absence of clearly defined attacks, the duration of attacks, and the temporal association between headache or other migrainous features and vestibular symptoms. Also, symptoms of vestibular migraine often overlap with symptoms of other causes of dizziness, especially Ménière's disease and benign paroxysmal positional vertigo (BPPV). This article will discuss the demographics, epidemiology, clinical manifestations, physical examination findings, laboratory testing, comorbidities, treatment options, and pathophysiology of vestibular migraine. Future research in the field of vestibular migraine should include both clinical and basic science efforts to better understand the pathophysiology of this condition. Controlled treatment trials for vestibular migraine are desperately needed.

The genetics of Ménière's disease

Our understanding of the genetic basis of Ménière’s disease (MD) is still limited. Although the familial clustering and the geographical and racial differences in incidence strongly suggest a certain role for genetic factors in the development of MD, no convincing evidence for an association with any gene exists, at present. In this review, starting from rational bases for a genetic approach to MD, we explored the numerous reports published in literature and summarize the recent advances in understanding of the genetic fundaments of the disease.

Accompanying Symptoms Overlap during Attacks in Menière's Disease and Vestibular Migraine

Menière’s disease and vestibular migraine (VM) are the most common causes of spontaneous recurrent vertigo. The current diagnostic criteria for the two disorders are mainly based on patients’ symptoms, and no biological marker is available. When applying these criteria, an overlap of the two disorders is occasionally observed in clinical practice. Therefore, the present prospective multicenter study aimed to identify accompanying symptoms that may help to differentiate between MD, VM, and probable vestibular migraine (pVM). Two hundred and sixty-eight patients were included in the study (MD: n = 119, VM: n = 84, pVM: n = 65). Patients with MD suffered mainly from accompanying auditory symptoms (tinnitus, fullness of ear, and hearing loss), while accompanying migraine symptoms (migraine-type headache, photo-/phonophobia, visual aura), anxiety, and palpitations were more common during attacks of VM. However, it has to be noted that a subset of MD patients also experienced (migraine-type) headache during the attacks. On the other hand, some VM/pVM patients reported accompanying auditory symptoms. The female/male ratio was statistically higher in VM/pVM as compared to MD, while the age of onset was significantly lower in the former two. The frequency of migraine-type headache was significantly higher in VM as compared to both pVM and MD. Accompanying headache of any type was observed in declining order in VM, pVM, and MD. In conclusion, the present study confirms a considerable overlap of symptoms in MD, VM, and pVM. In particular, we could not identify any highly specific symptom for one of the three entities. It is rather the combination of symptoms that should guide diagnostic reasoning. The identification of common symptom patterns in VM and MD may help to refine future diagnostic criteria for the two disorders.

Association of cinnarizine and betahistine in prophylactic therapy for Ménière's disease with and without migraine

Prophylactic therapy of Ménière's disease (MD) includes betahistine and calcium-blockers (the latter also useful for migraine prevention). The aim of our work was to assess the efficacy of combined therapy with cinnarizine and betahistine in MD subjects both with and without migraine and poorly responsive to betahistine alone. Fifty-two MD subjects were included who were poorly responsive to betahistine during 6 months of follow-up; 29 were migraineurs. Combined therapy was administered with betahistine 48 mg/day and cinnarizine 20 mg BID for 1 month, 20 mg/day for 2 weeks and 20 mg every 2 days for 2 more weeks, and then repeated. Results were collected over 6 months of follow-up. MD subjects with and without migraine demonstrated a decrease in both vertigo spells and migrainous attacks during combined therapy (from 9.4 to 3.8 and from 6.8 to 5.9 in 6 months, respectively, for vertigo spells, while migraine decreased from 3.8 to 1 in 6 months, respectively). A correlation was seen between decrease of vertigo spells and headaches in the sample of MD subjects with migraine. Our data support a proactive role for cinnarizine in preventing vertigo spells, especially in MD patients with migraine.

A missense variant of the ATP1A2 gene is associated with a novel phenotype of progressive sensorineural hearing loss associated with migraine

Hereditary sensorineural hearing loss is an extremely clinical and genetic heterogeneous disorder in humans. Especially, syndromic hearing loss is subdivided by combinations of various phenotypes, and each subtype is related to different genes. We present a new form of progressive hearing loss with migraine found to be associated with a variant in the ATP1A2 gene. The ATP1A2 gene has been reported as the major genetic cause of familial migraine by several previous studies. A Korean family presenting progressive hearing loss with migraine was ascertained. The affected members did not show any aura or other neurologic symptoms during migraine attacks, indicating on a novel phenotype of syndromic hearing loss. To identify the causative gene, linkage analysis and whole-exome sequencing were performed. A novel missense variant, c.571G>A (p.(Val191Met)), was identified in the ATP1A2 gene that showed co-segregation with the phenotype in the family. In silico studies suggest that this variant causes a change in hydrophobic interactions and thereby slightly destabilize the A-domain of Na(+)/K(+)-ATPase. However, functional studies failed to show any effect of the p.(Val191Met) substitution on the catalytic rate of this enzyme. We describe a new phenotype of progressive hearing loss with migraine associated with a variant in the ATP1A2 gene. This study suggests that a variant in Na(+)/K(+)-ATPase can be involved in both migraine and hearing loss.

Migraine and dizziness

PURPOSE OF REVIEW

Awareness of the importance of migraine in patients with symptoms of vestibular dysfunction is increasing. This article gives an overview of the multiple facets of the link between migraine and vestibular dysfunction.

RECENT FINDINGS

The vestibular and the headache community have published a consensual definition of vestibular migraine, which is an important step to promote research on the topic and the awareness of clinicians. Vestibular migraine is considered the most common cause of spontaneous recurrent vertigo. So far, the evidence for vestibular migraine has been mainly epidemiological, but the recent follow-up of a cohort over 9 years could show the robustness of the diagnosis over time.Additionally, migraine and vestibular dysfunction have multiple potential interactions and links through a range of comorbidities such as Menière's disease, benign paroxysmal positional vertigo, anxiety and motion sickness, which go beyond the diagnostic entity of vestibular migraine.

SUMMARY

The further refinement and wider acceptance of the diagnostic entity of vestibular migraine is an important development as it is one the most common vestibular disorders. But the relationship between migraine and vestibular dysfunction is complex and has many aspects beyond vestibular migraine.

Vestibular migraine

Background

The combination of vertigo, dizziness and balance disturbance with migraine is called vestibular migraine. Although it is estimated that up to 1% of the population suffers from this disease, it is still widely unknown and often underdiagnosed. Recently, the International Headache Society and the Báràny Society published the first joint document with mutually accepted diagnostic criteria for vestibular migraine.

Method

This review summarizes current knowledge on vestibular migraine with regard to epidemiology, clinical presentation, pathophysiology, differential diagnosis and therapeutic options.

Results

Approximately 30–50% of patients with migraine report vertigo, dizziness or balance disturbances with at least one migraine attack. Vestibular migraine often appears in a temporal delay to the first onset of migraine headache. In some patients the symptom of sudden onset disequilibrium was the main complaint and more worrisome than the accompanying migraine headache. The duration of attacks varies from a few seconds up to few days. The underlying pathophysiology of vestibular migraine is still widely unknown. As an important differential diagnosis, Ménière’s disease has to be considered and excluded.

Conclusion

As randomized controlled treatment trials are still missing in vestibular migraine, the therapeutic recommendations for vestibular migraine are currently based on the guidelines of migraine.