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Calandre EP, Bassila C, Slim M, Rico-Villademoros F. An overview of the current and emerging treatment options for vestibular migraine. Expert Rev Neurother 2024:1-23. [PMID: 39324692 DOI: 10.1080/14737175.2024.2405739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 09/13/2024] [Indexed: 09/27/2024]
Abstract
INTRODUCTION Vestibular migraine is a relatively common syndrome characterized by the occurrence of vertigo and other vestibular symptoms, frequently -but not always- accompanied by migraine symptoms, such as headache, photophobia, and phonophobia. AREAS COVERED The authors review the acute or abortive treatment during an attack and prophylactic treatment of vestibular migraines, including pharmacological and non-pharmacological options. EXPERT OPINION Since its recognition as an independent clinical entity is recent, studies concerning its different treatment alternatives are still scarce, and the level of evidence of published studies is generally low. For acute treatment, although available data are conflicting, triptans are usually tried first. Neurostimulating devices can also be considered for acute treatment of vestibular migraine. Regarding the preventive treatment of vestibular migraine, based on the results of two randomized clinical trials and its pharmacological properties, flunarizine should be considered as the first treatment option. Second-line preventive treatments encompass propranolol, topiramate, venlafaxine, and valproic acid. Among non-pharmacological options, vestibular rehabilitation seems to be a sound prophylactic treatment option.
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Affiliation(s)
- Elena P Calandre
- Instituto de Neurociencias, Universidad de Granada, Granada, Spain
| | | | - Mahmoud Slim
- Instituto de Neurociencias, Universidad de Granada, Granada, Spain
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Chrysouli K, Karamagkiolas S. Recent Trends in Treatment of Vestibular Migraine: A Systematic Review. Indian J Otolaryngol Head Neck Surg 2024; 76:2237-2243. [PMID: 38883465 PMCID: PMC11169333 DOI: 10.1007/s12070-024-04546-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Accepted: 02/04/2024] [Indexed: 06/18/2024] Open
Abstract
To summarize current knowledge of the literature on treatment of vestibular migraine. A review of the literature was conducted to collect all available published data on the treatment of vestibular migraine. The therapeutic approaches are based on case reports, retrospective cohort studies, and open-label trials from Medline search. Overall, 23 publications were related only to the specific treatment of vestibular migraine. Vestibular migraine remains still clinically under-diagnosed. Future studies are needed to understand the pathophysiological mechanisms and to introduce new effective therapies.
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Villar-Martinez MD, Goadsby PJ. Vestibular migraine: an update. Curr Opin Neurol 2024; 37:252-263. [PMID: 38619053 PMCID: PMC11064914 DOI: 10.1097/wco.0000000000001257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2024]
Abstract
PURPOSE OF REVIEW We performed a narrative review of the recent findings in epidemiology, clinical presentation, mechanisms and treatment of vestibular migraine. RECENT FINDINGS Vestibular migraine is an underdiagnosed condition that has a high prevalence among general, headache and neuro-otology clinics. Vestibular migraine has a bimodal presentation probably associated with a hormonal component in women. These patients could have a complex clinical phenotype including concomitant autonomic, inflammatory or connective tissue conditions that have a higher prevalence of psychological symptoms, which may mistakenly lead to a diagnosis of a functional neurological disorder. A high proportion of patients with postural perceptual persistent dizziness have a migraine phenotype. Independently of the clinical presentation and past medical history, patients with the vestibular migraine phenotype can respond to regular migraine preventive treatments, including those targeting the calcitonin gene-related peptide pathways. SUMMARY Vestibular migraine is an underdiagnosed migraine phenotype that shares the pathophysiological mechanisms of migraine, with growing interest in recent years. A thorough anamnesis is essential to increase sensitivity in patients with unknown cause of dizziness and migraine treatment should be considered (see supplemental video-abstract).
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Affiliation(s)
- Maria D. Villar-Martinez
- NIHR King's Clinical Research Facility, SLaM Biomedical Research Centre and Wolfson Sensory Pain and Regeneration, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
| | - Peter J. Goadsby
- NIHR King's Clinical Research Facility, SLaM Biomedical Research Centre and Wolfson Sensory Pain and Regeneration, Institute of Psychiatry, Psychology and Neuroscience, King's College London, UK
- Department of Neurology, University of California, Los Angeles, California, USA
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Pajaniappane A. Assessment and management of vestibular migraine within ENT. J Laryngol Otol 2024; 138:S22-S26. [PMID: 38291947 DOI: 10.1017/s0022215123002062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE Vestibular migraine is a newly recognised and debilitating condition. This article aims to provide an overview of what is known of vestibular migraine, delineating its diagnostic criteria and presenting some initial management strategies to aid ENT professionals in delivering optimal care when patients first present to the otolaryngology clinic. METHOD Although traditionally underdiagnosed, there are now clearly defined diagnostic criteria to aid accurate diagnosis of vestibular migraine. RESULTS A detailed history and clinical examination are the cornerstone of the diagnostic process, but supportive evidence is required from appropriate audio-vestibular tests and imaging. CONCLUSION This is a unique condition that commonly initially presents to ENT. This article provides a summary of diagnostic and management strategies to facilitate early diagnosis and first-line treatment that can be employed in general ENT settings, which may be particularly useful given the limited availability of specialist audio-vestibular medicine and neuro-otology services.
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Affiliation(s)
- Arun Pajaniappane
- Department of Audiovestibular Medicine, St George's University Hospitals NHS Trust, Tooting, UK
- Harley Street Audiovestibular Clinic, London, UK
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Ceriani CEJ. Vestibular Migraine Pathophysiology and Treatment: a Narrative Review. Curr Pain Headache Rep 2024; 28:47-54. [PMID: 37889468 DOI: 10.1007/s11916-023-01182-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/14/2023] [Indexed: 10/28/2023]
Abstract
PURPOSE OF REVIEW To review the diagnosis of vestibular migraine (VM) and update the clinician on the most recent developments in our understanding of its pathophysiology and treatment. RECENT FINDINGS Functional imaging studies have identified multiple regions of the brain with abnormal activity and connectivity in VM. There is evidence of abnormal sensory processing and integration in VM patients. Calcitonin gene-related peptide (CGRP) has also been found to play a role in trigeminal and vestibular nucleus pathways. Research into treatment modalities has identified several neuromodulation devices that may be effective in VM. There are a growing number of evidence-based preventive options for VM, including medications that target CGRP. VM is best understood as a sensory processing disorder. CGRP appears to play a role, and further research is needed to fully understand its effects. Treatment options are expanding, but there is still a need for more randomly controlled trials in this area.
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Affiliation(s)
- Claire E J Ceriani
- Jefferson Headache Center, Department of Neurology, Thomas Jefferson University, 900 Walnut St., Ste 200, Philadelphia, PA, 19107, USA.
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Tak Y, Tassone F, Hagerman RJ. Case Series: Vestibular Migraines in Fragile X Premutation Carriers. J Clin Med 2024; 13:504. [PMID: 38256638 PMCID: PMC10816080 DOI: 10.3390/jcm13020504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/24/2024] Open
Abstract
BACKGROUND Vestibular migraine (VM) is one of the most common causes of recurrent vertigo and presents with a history of spontaneous or positional vertigo with a history of migraine headaches. While research has identified a high prevalence of migraine headaches and vestibular deficits among fragile X premutation carriers, there has been no discussion about VM within this population. OBJECTIVE This case series and review seeks to describe the clinical characteristics and pathophysiology of VM among individuals with the fragile X premutation. We also seek to discuss treatment and future steps in addressing VM in this population. METHODS A review of the literature regarding vestibular migraine and presentation of migraine headaches and vestibular deficits among premutation carriers was performed. A detailed clinical history of migraine headaches and vertigo was obtained from three patients with the fragile X premutation seen by the senior author (RJH). RESULTS All three cases first developed symptoms of migraine headaches earlier in life, with the development of VM near menopause. Two of the three cases developed progressive balance issues following the development of VM. All three cases found that their VM episodes were improved or resolved with pharmacological and/or lifestyle interventions. CONCLUSIONS It is important to recognize VM among premutation carriers because beneficial treatments are available. Future studies are needed regarding the prevalence of VM and the relationship to subsequent FXTAS. The pathophysiology of VM remains uncertain but possibilities include mitochondrial abnormalities, cranial nerve VIII toxicity secondary to neurotoxic protein accumulation, and calcitonin gene-related peptide (CGRP) signaling dysfunction due to altered levels of fragile X messenger ribonucleoprotein (FMRP).
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Affiliation(s)
- YeEun Tak
- University of California Davis School of Medicine, Sacramento Campus, Sacramento, CA 95817, USA; (Y.T.); (F.T.)
- Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, University of California Davis Health, Sacramento, CA 95616, USA
| | - Flora Tassone
- University of California Davis School of Medicine, Sacramento Campus, Sacramento, CA 95817, USA; (Y.T.); (F.T.)
- Department of Biochemistry and Molecular Medicine, University of California Davis, Sacramento, CA 95817, USA
| | - Randi J. Hagerman
- University of California Davis School of Medicine, Sacramento Campus, Sacramento, CA 95817, USA; (Y.T.); (F.T.)
- Department of Pediatrics, University of California Davis Health, Sacramento, CA 95817, USA
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Tighilet B, Trico J, Marouane E, Zwergal A, Chabbert C. Histaminergic System and Vestibular Function in Normal and Pathological Conditions. Curr Neuropharmacol 2024; 22:1826-1845. [PMID: 38504566 PMCID: PMC11284731 DOI: 10.2174/1570159x22666240319123151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 09/20/2023] [Accepted: 10/13/2023] [Indexed: 03/21/2024] Open
Abstract
Most neurotransmitter systems are represented in the central and peripheral vestibular system and are thereby involved both in normal vestibular signal processing and the pathophysiology of vestibular disorders. However, there is a special relationship between the vestibular system and the histaminergic system. The purpose of this review is to document how the histaminergic system interferes with normal and pathological vestibular function. In particular, we will discuss neurobiological mechanisms such as neuroinflammation that involve histamine to modulate and allow restoration of balance function in the situation of a vestibular insult. These adaptive mechanisms represent targets of histaminergic pharmacological compounds capable of restoring vestibular function in pathological situations. The clinical use of drugs targeting the histaminergic system in various vestibular disorders is critically discussed.
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Affiliation(s)
- Brahim Tighilet
- Aix Marseille Université-CNRS, Laboratoire de Neurosciences Cognitives, LNC UMR 7291, Marseille, Groupe de Recherche Vertige (GDR#2074), France
| | - Jessica Trico
- Aix Marseille Université-CNRS, Laboratoire de Neurosciences Cognitives, LNC UMR 7291, Marseille, Groupe de Recherche Vertige (GDR#2074), France
| | - Emna Marouane
- Aix Marseille Université-CNRS, Laboratoire de Neurosciences Cognitives, LNC UMR 7291, Marseille, Groupe de Recherche Vertige (GDR#2074), France
- Normandie Université, UNICAEN, INSERM, COMETE, CYCERON, CHU Caen, 14000, Caen, France
| | - Andreas Zwergal
- Department of Neurology, LMU University Hospital, Munich, Germany
- German Center for Vertigo and Balance Disorders, LMU University Hospital, Munich, Germany
| | - Christian Chabbert
- Aix Marseille Université-CNRS, Laboratoire de Neurosciences Cognitives, LNC UMR 7291, Marseille, Groupe de Recherche Vertige (GDR#2074), France
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Togha M, Babaei M, Jameie M. Good response to rectal diazepam in refractory cases of cyclic vomiting: A case-series and review of the literature. Clin Case Rep 2023; 11:e8109. [PMID: 38028097 PMCID: PMC10661318 DOI: 10.1002/ccr3.8109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 07/19/2023] [Accepted: 08/28/2023] [Indexed: 12/01/2023] Open
Abstract
Key Clinical Message Although increasing in number, cases of CVS are being frequently misdiagnosed and many are refractory to the available treatments. This paper draws attention to a timely consideration of this disorder upon suspicion and proposes rectal diazepam and cinnarizine as highly effective treatments in refractory cases of CVS. Abstract Cyclic vomiting syndrome (CVS) is a set of recurrent episodic attacks of nausea and vomiting. This is a migraine-related disorder that mostly affects children. Several medications have been recommended for abortive and prophylactic treatment. Unfortunately, in some cases, the treatment is not completely effective and affects the quality of life of the sufferer. In this paper, we report on two cases of children experiencing refractory CVS attacks who were not responsive to recommended medications for acute phase and prophylaxis. This account highlights the efficacy of rectal diazepam for the acute phase of CVS and cinnarizine, an anti-migraine and anti-histamine agent, for prophylaxis of further attacks.
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Affiliation(s)
- Mansoureh Togha
- Neurology department, Sina Hospital, School of MedicineTehran University of Medical SciencesTehranIran
- Headache department, Iranian Center of Neurological Research, Neuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Mahsa Babaei
- Headache department, Iranian Center of Neurological Research, Neuroscience InstituteTehran University of Medical SciencesTehranIran
| | - Melika Jameie
- Headache department, Iranian Center of Neurological Research, Neuroscience InstituteTehran University of Medical SciencesTehranIran
- Iranian Center of Neurological Research, Neuroscience InstituteTehran University of Medical SciencesTehranIran
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Yiannakis C, Hamilton L, Slim M, Kontorinis G. A systematic review and meta-analysis of prophylactic medication of vestibular migraine. J Laryngol Otol 2023; 137:953-961. [PMID: 36200521 DOI: 10.1017/s0022215122001979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVE Vestibular migraine is in the process of recognition as an individual clinical entity. At present, no guidelines exist for its management. This study aimed to conduct a systematic review and meta-analysis to determine the effectiveness of available prophylactic medication. METHOD A literature search was performed using PubMed, Ovid and Embase databases. Qualitative and quantitative analysis were performed as well as risk of bias analysis. Meta-analysis for the mean differences for pre- and post-treatment impact based on Dizziness Handicap Inventory and Vertigo Symptom Scale were performed. Proportionate transformation meta-analysis for the successful event rate based on complete symptoms control was explored. RESULTS Thirteen publications were identified: 3 were randomised, controlled trials and 10 were non-randomised, controlled trials. Propranolol and venlafaxine improved the Vertigo Symptom Scale score by -13.31 points and -4.16 points, respectively, and the Dizziness Handicap Inventory score by -32.24 and -21.24, respectively. Only propranolol achieved statistically significant impact with 60 per cent of patients achieving complete symptom control. CONCLUSION Propranolol should be offered as the first-line treatment for vestibular migraine followed by venlafaxine. Amitriptyline, flunarizine and cinnarizine showed a trend for symptom improvement, but this was not statistically significant.
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Affiliation(s)
- C Yiannakis
- Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - L Hamilton
- Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - M Slim
- Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - G Kontorinis
- Department of Otolaryngology, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
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Kim EK, Seguya A, Thaw MH, Tahir P, Formeister EJ, Waterworth CJ, Jaffer AF. Vestibular migraine in low- and lower-middle-income countries: A scoping review. J Otol 2023; 18:173-184. [PMID: 37497329 PMCID: PMC10366582 DOI: 10.1016/j.joto.2023.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 05/17/2023] [Indexed: 07/28/2023] Open
Abstract
Background Vestibular migraine (VM) is a common cause of dizziness that is underrecognized, underdiagnosed, and challenging to effectively treat. The prevalence, appropriate diagnostic workup, and therapies for VM in low- and lower-middle-income countries (LLMICs) remain understudied. The objective of this scoping review is to evaluate the current state of VM research in LLMICs. Methods PubMed, Embase, and Web of Science databases were searched to execute a scoping review of VM. Keywords "vestibular diseases" and "vertigo" were used in combination with terms referring to LLMICs as defined by the World Bank. Title and abstract screening, full-text review, and data collection were conducted by two authors independently. Results Twenty-six studies were included in the scoping review. Most studies were cross-sectional (57.7%) or case studies/series (23.1%) and were conducted in urban settings only (92.3%). Geographic distribution of studies was skewed, with 65.4% of articles originating from India. The prevalence of VM among clinic patients ranged from 0.3% to 33.3%. VM most frequently presented as headache, nausea and vomiting, and photophobia. Radiographic imaging, audiometry, and electronystagmography/videonystagmography were the three most commonly utilized diagnostic modalities in the dizziness workup. The most studied pharmacotherapies included calcium channel blockers, followed by beta-blockers and antiepileptics. Case studies and series discussed less common VM pharmacotherapies, such as ayurvedic medicine. Conclusions There is a need for more VM research in LLMICs, including innovative diagnostic approaches and therapies that can improve VM care globally. Equitable partnerships between LLMIC and high-income country researchers must expand vestibular research capacity and productivity in LLMICs.
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Affiliation(s)
- Eric K. Kim
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- Department of Otolaryngology - Head and Neck Surgery, University of California, San Francisco, San Francisco, CA, USA
| | - Amina Seguya
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- Ear, Nose and Throat Surgeon, Mulago National Referral Hospital, Kampala, Uganda
| | - May Htoo Thaw
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- Eye, ORL-HNS Hospital, Mandalay, Myanmar
| | - Peggy Tahir
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- UCSF Library, University of California, San Francisco, CA, USA
| | - Eric J. Formeister
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- Department of Otolaryngology - Head and Neck Surgery, Duke University, Durham, NC, USA
| | - Christopher J. Waterworth
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- Department of Audiology and Speech Pathology, The University of Melbourne, Victoria, Australia
- Nossal Institute for Global Health, University of Melbourne, Victoria, Australia
| | - Ali F. Jaffer
- The Global Otolaryngology-Head and Neck Surgery Initiative, USA
- HearWell Audiology Clinic, Dar es Salaam, Tanzania
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Teelucksingh S, Murali Govind R, Dobson R, Nelson-Piercy C, Ovadia C. Treating Vestibular Migraine When Pregnant and Postpartum: Progress, Challenges and Innovations. Int J Womens Health 2023; 15:321-338. [PMID: 36814528 PMCID: PMC9940493 DOI: 10.2147/ijwh.s371491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Accepted: 01/18/2023] [Indexed: 02/18/2023] Open
Abstract
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.
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Affiliation(s)
- Siara Teelucksingh
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Renuka Murali Govind
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
| | - Ruth Dobson
- Preventive Neurology Unit, Queen Mary University of London, London, UK
- Department of Neurology, Royal London Hospital, London, UK
| | - Catherine Nelson-Piercy
- Department of Obstetric Medicine, Guy’s and St. Thomas’ NHS Foundation Trust, London, UK
- Department of Women and Children’s Health, King’s College London, London, UK
| | - Caroline Ovadia
- Department of Women and Children’s Health, King’s College London, London, UK
- Department of Obstetrics and Gynaecology, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
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Smyth D, Britton Z, Murdin L, Arshad Q, Kaski D. Vestibular migraine treatment: a comprehensive practical review. Brain 2022; 145:3741-3754. [PMID: 35859353 DOI: 10.1093/brain/awac264] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/18/2022] [Accepted: 07/01/2022] [Indexed: 11/12/2022] Open
Abstract
Vestibular migraine is an underdiagnosed but increasingly recognised neurological condition that causes episodic vertigo associated with other features of migraine. It is now thought to be the most common cause of spontaneous (non-positional) episodic vertigo, affecting up to 1% of the population. A meta-analysis of preventative treatments for vestibular migraine was published in 2021 but the authors were unable to establish a preferred treatment strategy due to low quality of evidence and heterogeneity of study design and outcome reporting. There remains therefore a clinical need for pragmatic management guidelines specific to vestibular migraine using the available evidence. Here we provide a practical review utilising a systematic qualitative assessment of the evidence for abortive and preventative interventions in adults. The overall evidence base for vestibular migraine treatment is of low quality. Nevertheless, we provide practical treatment recommendations based on the available evidence and our experience to help guide clinicians treating patients with vestibular migraine. We also discuss how future clinical trials could be designed to improve the quality of evidence in this condition.
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Affiliation(s)
- Duncan Smyth
- Department of Neuro-Otology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Zelie Britton
- Department of Neuro-Otology, National Hospital for Neurology and Neurosurgery, London, UK
| | - Louisa Murdin
- Guy's and St Thomas' NHS Foundation Trust, London, UK; and Ear Institute, Faculty of Brain Sciences, University College London, London, UK
| | - Qadeer Arshad
- Department of Neuroscience, Psychology and Behaviour, University of Leicester, Leicester, UK
| | - Diego Kaski
- Department of Neuro-Otology, National Hospital for Neurology and Neurosurgery, London, UK
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Viola P, Marcianò G, Casarella A, Pisani D, Astorina A, Scarpa A, Siccardi E, Basile E, De Sarro G, Gallelli L, Chiarella G. The Pharmacological Treatment of Pediatric Vertigo. CHILDREN 2022; 9:children9050584. [PMID: 35626761 PMCID: PMC9139449 DOI: 10.3390/children9050584] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 04/09/2022] [Accepted: 04/15/2022] [Indexed: 12/25/2022]
Abstract
Vertigo in children is a challenging topic. The lack of dedicated trials, guidelines and papers causes inhomogeneity in the treatment of vertigo in children. Meniere’s disease, migraine equivalents, vestibular neuritis, paroxysmal positional benign vertigo (BPPV), persistent postural-perceptual dizziness (PPPD) and motion sickness may affect children with various degrees of incidence and clinical severity compared to adults. Several drugs are proposed for the management of these conditions, even if their use is subordinated to the child’s age. In this review, we summarize the existing evidence related to the use of drugs for this clinical condition in children as a start point for new trials, stating the urgent need for international guidelines.
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Affiliation(s)
- Pasquale Viola
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Gianmarco Marcianò
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Alessandro Casarella
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Davide Pisani
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Alessia Astorina
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
| | - Alfonso Scarpa
- Department of Medicine and Surgery, University of Salerno, 84081 Baronissi, Italy;
| | | | - Emanuele Basile
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
| | - Giovambattista De Sarro
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
- Research Center FAS@UMG, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Luca Gallelli
- Clinical Pharmacology and Pharmacovigilance Unit, Department of Health Science, School of Medicine, University of Catanzaro, Mater Domini Hospital, 88100 Catanzaro, Italy; (G.M.); (A.C.); (E.B.); (G.D.S.); (L.G.)
- Research Center FAS@UMG, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
- Medifarmagen SRL, Department of Health Science, Magna Graecia University, 88100 Catanzaro, Italy
| | - Giuseppe Chiarella
- Unit of Audiology, Regional Centre of Cochlear Implants and ENT Diseases, Department of Experimental and Clinical Medicine, Magna Graecia University, 88100 Catanzaro, Italy; (P.V.); (D.P.); (A.A.)
- Correspondence: ; Tel.: +39-0961364-7124
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Kısabay Ak A, Çelebisoy N, Özdemir HN, Gökçay F, Saruhan Durmaz G, Top Kartı D, Ertaşoğlu Toydemir H, Yayla V, Çolpak Işıkay Aİ, Erkent İ, Özçelik P, Akdal G, Ataç C, Bıçakcı Ş, Ozaydın-Göksu E, Güleç Uyaroğlu F. Factors determining the response to treatment in patients with vestibular migraine. Neurol Res 2022; 44:847-854. [PMID: 35348034 DOI: 10.1080/01616412.2022.2056341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE To find out clinical features associated with poor response to treatment in vestibular migraine (VM). METHODS VM patients treated with drugs recommended in migraine prophylaxis were included in this multicenter study. Migraine features including type, age of onset of headache and vertigo attacks, attack frequency, intensity, associated symptoms, triggering factors, presence of interictal dizziness/imbalance, anxiety, depression, history of motion sickness, and family history of migraine were noted. Amitriptyline, flunarizine, propranolol, topiramate and venlafaxine were chosen depending on patients' individual requirements. Maximum dose of each drug was tried for 2 months to decide its efficacy. In the case of inefficacy, it was changed with another preventive drug of different class. If there was still no improvement, two drugs of different classes were combined. ≥ 50% reduction in attack frequency and severity in patients using one drug and a combination of two drugs was compared, with patients showing <50% reduction despite combination therapy, regarding their clinical features. RESULTS The results of 430 VM patients, 65 men and 365 women with a mean age of 42.2 ± 12.2 years (range: 17-74 years), were analyzed. CONCLUSION Cutaneous allodynia frequently associated with female sex, comorbid anxiety and depression and interictal dizziness/imbalance enhanced with comorbid anxiety were risk factors for reduced treatment response. Aural fullness might be the clue of impending concomitant Meniere's disease not responding to migraine preventives.
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Affiliation(s)
| | | | | | - Figen Gökçay
- Department of Neurology, Ege University, Izmir, Turkey
| | | | - Dilek Top Kartı
- Department of Neurology, University of Health Sciences Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Hülya Ertaşoğlu Toydemir
- Department of Neurology, University of Health Sciences Istanbul Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | - Vildan Yayla
- Department of Neurology, University of Health Sciences Istanbul Bakırköy Dr. Sadi Konuk Education and Research Hospital, Istanbul, Turkey
| | | | - İrem Erkent
- Department of Neurology, Hacettepe University, Ankara, Turkey
| | - Pınar Özçelik
- Department of Neurology, Dokuz Eylül University, Izmir, Turkey
| | - Gülden Akdal
- Department of Neurology, Dokuz Eylül University, Izmir, Turkey
| | - Ceyla Ataç
- Department of Neurology, University of Health Sciences Izmir Bozyaka Education and Research Hospital, Izmir, Turkey
| | - Şebnem Bıçakcı
- Department Of Neurology, Çukurova University, Adana, Turkey
| | - Eylem Ozaydın-Göksu
- Department of Neurology, University of Health Sciences Antalya Education and Research Hospital, Antalya, Turkey
| | - Feray Güleç Uyaroğlu
- Department of Neurology, University of Health Sciences Izmir Tepecik Education and Research Hospital, Izmir, Turkey
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15
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Belyaeva II, Subbotina AG, Eremenko II, Tarasov VV, Chubarev VN, Schiöth HB, Mwinyi J. Pharmacogenetics in Primary Headache Disorders. Front Pharmacol 2022; 12:820214. [PMID: 35222013 PMCID: PMC8866828 DOI: 10.3389/fphar.2021.820214] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 12/23/2021] [Indexed: 11/09/2022] Open
Abstract
Primary headache disorders, such as migraine, tension-type headache (TTH), and cluster headache, belong to the most common neurological disorders affecting a high percentage of people worldwide. Headache induces a high burden for the affected individuals on the personal level, with a strong impact on life quality, daily life management, and causes immense costs for the healthcare systems. Although a relatively broad spectrum of different pharmacological classes for the treatment of headache disorders are available, treatment effectiveness is often limited by high variances in therapy responses. Genetic variants can influence the individual treatment success by influencing pharmacokinetics or pharmacodynamics of the therapeutic as investigated in the research field of pharmacogenetics. This review summarizes the current knowledge on important primary headache disorders, including migraine, TTH, and cluster headache. We also summarize current acute and preventive treatment options for the three headache disorders based on drug classes and compounds taking important therapy guidelines into consideration. Importantly, the work summarizes and discusses the role of genetic polymorphisms regarding their impact on metabolism safety and the effect of therapeutics that are used to treat migraine, cluster headache, and TTH exploring drug classes such as nonsteroidal anti-inflammatory drugs, triptans, antidepressants, anticonvulsants, calcium channel blockers, drugs with effect on the renin-angiotensin system, and novel headache therapeutics such as ditans, anti-calcitonin-gene-related peptide antibodies, and gepants. Genetic variants in important phase I-, II-, and III-associated genes such as cytochrome P450 genes, UGT genes, and different transporter genes are scrutinized as well as variants in genes important for pharmacodynamics and several functions outside the pharmacokinetic and pharmacodynamic spectrum. Finally, the article evaluates the potential and limitations of pharmacogenetic approaches for individual therapy adjustments in headache disorders.
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Affiliation(s)
- Irina I. Belyaeva
- Department of Surgical Sciences, Functional Pharmacology and Neuroscience, University of Uppsala, Uppsala, Sweden,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Anna G. Subbotina
- Department of Surgical Sciences, Functional Pharmacology and Neuroscience, University of Uppsala, Uppsala, Sweden,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ivan I. Eremenko
- Department of Surgical Sciences, Functional Pharmacology and Neuroscience, University of Uppsala, Uppsala, Sweden,Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vadim V. Tarasov
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia,Institute of Translational Medicine and Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Vladimir N. Chubarev
- Department of Pharmacology, Institute of Pharmacy, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Helgi B. Schiöth
- Department of Surgical Sciences, Functional Pharmacology and Neuroscience, University of Uppsala, Uppsala, Sweden,Institute of Translational Medicine and Biotechnology, I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Jessica Mwinyi
- Department of Surgical Sciences, Functional Pharmacology and Neuroscience, University of Uppsala, Uppsala, Sweden,*Correspondence: Jessica Mwinyi,
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16
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Abstract
Medical therapies for dizziness are aimed at vertigo reduction, secondary symptom management, or the root cause of the pathologic process. Acute peripheral vertigo pharmacotherapies include antihistamines, calcium channel blockers, and benzodiazepines. Prophylactic pharmacotherapies vary between causes. For Meniere disease, betahistine and diuretics remain initial first-line oral options, whereas intratympanic steroids and intratympanic gentamicin are reserved for uncontrolled symptoms. For cerebellar dizziness and oculomotor disorders, 4-aminopyridine may provide benefit. For vestibular migraine, persistent postural perceptual dizziness and mal de débarquement, treatment options overlap and include selective serotonin reuptake inhibitors, serotonin-norepinephrine reuptake inhibitors, tricyclic antidepressants and calcium channel blockers.
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Affiliation(s)
- Mallory J Raymond
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, 135 Rutledge Avenue MSC 550, 11th Floor, Charleston, SC 29425, USA
| | - Esther X Vivas
- Department of Otolaryngology-Head and Neck Surgery, Emory University School of Medicine, 550 Peachtree Street Northeast, 11th Floor, Atlanta, GA 30308, USA.
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17
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Wu Z, Hu M, Jin Y, Li J, Wu W, Jiang H. Synthesis of medicinally relevant oxalylamines via copper/Lewis acid synergistic catalysis. SCIENCE ADVANCES 2021; 7:eabh4088. [PMID: 34452916 PMCID: PMC8397263 DOI: 10.1126/sciadv.abh4088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/07/2021] [Accepted: 07/07/2021] [Indexed: 06/13/2023]
Abstract
Allylamines have long been recognized as valuable synthons because of their excellent reactivity in organic synthesis. Here, an efficient amination reaction of allenyl ethers via copper/Lewis acid synergistic catalysis has been established, providing straightforward access to diverse functionalized Z-oxalylamines and E -halogenated oxalylamines in good to excellent yields with high regio- and stereoselectivities. The developed method tolerates more than 100 examples that include late-stage functionalization of bioactive molecules, and features gram-scale synthesis of oxalylamines with high turnover number (TON > 1000) under mild and simple conditions. The applicability of the protocol is further demonstrated with the construction of drug molecules.
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Affiliation(s)
- Ziying Wu
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China
| | - Miao Hu
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China
| | - Yangbin Jin
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China
| | - Jianxiao Li
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China
| | - Wanqing Wu
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China.
| | - Huanfeng Jiang
- Key Laboratory of Functional Molecular Engineering of Guangdong Province, School of Chemistry and Chemical Engineering, South China University of Technology, Guangzhou 510640, China.
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Abstract
PURPOSE OF REVIEW Conditions causing recurrent spontaneous episodes of dizziness or vertigo span several medical specialties, making it challenging for clinicians to gain confidence in evaluating and managing the spectrum of episodic vestibular disorders. Patients are often asymptomatic and have normal examinations at the time of evaluation. Thus, diagnosis depends heavily on eliciting key features from the history. Overreliance on symptom quality descriptions commonly leads to misdiagnosis. The goal of this article is to provide the reader with a straightforward approach to the diagnosis and management of conditions that cause episodic spontaneous dizziness. RECENT FINDINGS Consensus diagnostic criteria have been established for vestibular migraine, Ménière disease, vestibular paroxysmia, and hemodynamic orthostatic dizziness/vertigo. Vertigo has been recognized as a common symptom in vertebrobasilar ischemia, cardiogenic dizziness, and orthostatic hypotension. Treatment recommendations for vestibular migraine still lack high-quality evidence, but controlled trials are occurring. SUMMARY The evaluation should start with a detailed description of the episodes from the patient and any observers. Rather than focusing first on whether the symptom quality is most consistent with vertigo, dizziness, lightheadedness, or unsteadiness, the clinician should clarify the timing (episode frequency and duration), possible triggers or circumstances (eg, position changes, upright posture), and accompanying symptoms. History should identify any auditory symptoms, migraine features, posterior circulation ischemic symptoms, vascular risk factors, clues for anxiety, and potentially relevant medications. Carefully selected testing can help secure the diagnosis, but excessive and indiscriminate testing can lead to more confusion. Treatments for these conditions are vastly different, so an accurate diagnosis is critical.
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Vestibular migraine: the chameleon in vestibular disease. Neurol Sci 2021; 42:1719-1731. [PMID: 33666767 DOI: 10.1007/s10072-021-05133-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2020] [Accepted: 02/20/2021] [Indexed: 12/19/2022]
Abstract
Vestibular migraine (VM) has been recently receiving increasing attention as an independent disease concept. It is a common cause of dizziness or headache; however, it was not clearly defined until 2018. Its diagnosis mainly relies on clinical history, including vertigo and migraine, as indicated by the appendix of the 3rd edition of the International Classification Diagnostic Criteria for Headache Diseases. There is often an overlap of vertigo and migraine across vestibular diseases; therefore, VM often imitates various vestibular diseases. Additionally, VM lacks specific laboratory biomarkers; therefore, it has high misdiagnosis and missed diagnosis rates. Therefore, numerous clinical patients could have inaccurate diagnoses and improper treatment. Therefore, there is a need for further basic research to further clarify the pathogenesis. Moreover, there is a need for clinical trials focusing on specific laboratory biomarkers, including serological, radiological, and electrophysiological examinations, to develop more detailed and complete diagnostic criteria.
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20
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Shen Y, Qi X, Wan T. The Treatment of Vestibular Migraine: A Narrative Review. Ann Indian Acad Neurol 2021; 23:602-607. [PMID: 33623258 PMCID: PMC7887465 DOI: 10.4103/aian.aian_591_19] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2019] [Revised: 11/22/2019] [Accepted: 12/25/2019] [Indexed: 11/06/2022] Open
Abstract
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.
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Affiliation(s)
- Youjin Shen
- Southern Medical University, Guangzhou City, Guangdong Province, Beijing, China
| | - Xiaokun Qi
- Department of Neurology, The Sixth Medical Center of PLA of China General Hospital, Beijing, China
| | - Tingyu Wan
- Department of Neurology, The People's Hospital of Jiangmen, Jiangmen City, Guangdong Province, China
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21
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Togha M, Martami F, Abdollahi M, Mozafari M, Cheraghali H, Rafiee P, Shafaei M. Cinnarizine as an alternative recommendation for migraine prophylaxis: a narrative review. Expert Rev Neurother 2020; 20:943-951. [PMID: 32597267 DOI: 10.1080/14737175.2020.1787834] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Despite the available prophylactic and acute drugs for migraine management, this disabling disorder remains undertreated especially among pediatrics. In this review, the authors aim at assessing the preventive role cinnarizine plays in treating migraine based on previously published studies. AREAS COVERED Randomized clinical trials, randomized controlled trials, non-randomized open-label trials, and retrospective studies concerning cinnarizine in migraine prevention in children and adults were reviewed. Especial attention was given to the response rate, migraine characteristics, and tolerability. EXPERT OPINION The majority of reviewed trials demonstrated that cinnarizine is comparable to the conventional drugs used in migraine prophylaxis. However, most of the reviewed studies were limited by a non-controlled open-label design. Due to poor planning and possibility of high placebo responses, particularly in children and adolescents, the interpretation of open-label studies' results should be done cautiously. The evidence shows that cinnarizine's effectiveness was more promising in pediatric migraineurs and adults with migraine-associated vertigo such as vestibular migraine. Therefore, while the efficacy of cinnarizine cannot be dismissed, before reaching a definite conclusion on its effectiveness, it is necessary to do further high-quality RCTs among both children and adults.
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Affiliation(s)
- Mansoureh Togha
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences , Tehran, Iran.,Department of Neurology, Sina Hospital, Tehran University of Medical Sciences , Tehran, Iran
| | - Fahime Martami
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences , Tehran, Iran
| | - Mohammad Abdollahi
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences , Tehran, Iran
| | - Mohammad Mozafari
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences , Tehran, Iran
| | - Hamed Cheraghali
- Students' Scientific Research Center (SSRC), Tehran University of Medical Sciences , Tehran, Iran
| | - Pegah Rafiee
- Student Research Committee, (Department and Faculty of Nutrition Sciences and Food Technology), Shahid Beheshti University of Medical Sciences , Tehran, Iran
| | - Maryam Shafaei
- Headache Department, Iranian Center of Neurological Research, Neuroscience Institute, Tehran University of Medical Sciences , Tehran, Iran
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Abstract
The diagnosis and management of vertigo remains a challenge for clinicians, including general neurology. In recent years there have been advances in the understanding of established vestibular syndromes, and the development of treatments for existing vestibular diagnoses. In this 'update' I will review how our understanding of previously "unexplained" dizziness in the elderly is changing, explore novel insights into the pathophysiology of vestibular migraine, and its relationship to the newly coined term 'persistent postural perceptual dizziness', and finally discuss how a simple bedside oculomotor assessment may help identify vestibular presentations of stroke.
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Affiliation(s)
- Diego Kaski
- Department of Neurology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK. .,Centre for Vestibular and Behavioural Neurosciences, Department of Clinical and Motor Neurosciences, University College London, 33 Queen Square, London, WC1N 3BG, UK.
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23
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Byun YJ, Levy DA, Nguyen SA, Brennan E, Rizk HG. Treatment of Vestibular Migraine: A Systematic Review and Meta-analysis. Laryngoscope 2020; 131:186-194. [PMID: 32083732 DOI: 10.1002/lary.28546] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 01/06/2020] [Accepted: 01/10/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the efficacy of the various therapies used for the prevention of vestibular migraine (VM). METHODS Primary studies were identified though PubMed, Scopus, PsycINFO, and Cochrane Library by two independent investigators for articles published through April 2019. The search identified randomized comparison or observational studies pertaining to vestibular migraine treatment. Meta-analysis was performed on pre- and posttreatment Dizziness Handicap Inventory, vertigo frequency, and percentage of perceived improvement. RESULTS Literature search identified 13 studies that reported sufficient outcome measures to be included in the analysis. Patients with VM had a mean age of 43.3 years with female-to-male gender ratio of 2.1:1. Classes of therapeutic agents included antiepileptic drugs, calcium channel blockers, tricyclic antidepressants, β-blockers, serotonin and norepinephrine reuptake inhibitors, and vestibular rehabilitation. All treatment options that were analyzed demonstrated improvement in all of the outcome parameters, but due to significant heterogeneity and lack of standardized reporting on outcomes, establishment of preferred treatment modality could not be determined. CONCLUSIONS Various treatment modalities have been evaluated for preventative treatment of VM. Physician familiarity, patient comorbidities, and the side-effect profiles of various interventions likely influence the selection of intervention. Future randomized controlled trials with restrictive inclusion criteria and generalizable standardized outcome measures will allow for more robust meta-analyses and for more evidence-based treatment of vestibular migraines. Laryngoscope, 131:186-194, 2021.
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Affiliation(s)
- Young Jae Byun
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.,Department of Medicine, University of Central Florida College of Medicine, Orlando, Florida
| | - Dylan A Levy
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina.,Department of Medicine, Quinnipiac University Frank H. Netter MD School of Medicine, North Haven, Connecticut
| | - Shaun A Nguyen
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
| | - Emily Brennan
- Department of Research and Education Services, Medical University of South Carolina Library, Charleston, South Carolina, U.S.A
| | - Habib G Rizk
- Department of Otolaryngology-Head and Neck Surgery, Medical University of South Carolina, Charleston, South Carolina
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Tanıgör G, Aydin İ, Gökçay F, Karapolat H, Eraslan S, Bilgen C, Kirazli T, Köse T, Çelebisoy N. Effects of vestibular rehabilitation and pharmacological therapy in patients with vestibular migraine. NEUROL SCI NEUROPHYS 2020. [DOI: 10.4103/nsn.nsn_41_20] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Huang TC, Wang SJ, Kheradmand A. Vestibular migraine: An update on current understanding and future directions. Cephalalgia 2019; 40:107-121. [PMID: 31394919 DOI: 10.1177/0333102419869317] [Citation(s) in RCA: 74] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
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.
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Affiliation(s)
- Tzu-Chou Huang
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Living Water Neurological Clinic, Tainan, Taiwan
| | - Shuu-Jiun Wang
- Neurological Institute, Taipei-Veterans General Hospital, Taipei, Taiwan.,Brain Research Center and School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Amir Kheradmand
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.,Department of Otolaryngology-Head and Neck Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Dyhrfjeld-Johnsen J, Attali P. Management of peripheral vertigo with antihistamines: New options on the horizon. Br J Clin Pharmacol 2019; 85:2255-2263. [PMID: 31269270 DOI: 10.1111/bcp.14046] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 06/06/2019] [Accepted: 06/10/2019] [Indexed: 12/12/2022] Open
Abstract
Vertigo is associated with a wide range of vestibular pathologies. It increasingly affects the elderly, with a high cost to society. Solutions include vestibular suppressants and vestibular rehabilitation, which form the mainstay of therapy. Antihistamines represent the largest class of agents used to combat vestibular vertigo symptoms. Agents targeting the H1 and H3 receptors have been in clinical use for several decades as single agents. Nonetheless, effective management of vertigo proves elusive as many treatments largely address only associated symptoms, and with questionable efficacy. Additionally, the primary and limiting side effect of sedation is counterproductive to normal functioning and the natural recovery process occurring via central compensation. To address these issues, the timing of administration of betahistine, the mainstay H3 antihistamine, can be fine-tuned, while bioavailability is also being improved. Other approaches include antihistamine combination studies, devices, physical therapy and behavioural interventions. Recently demonstrated expression of H4 receptors in the peripheral vestibular system represents a new potential drug target for treating vestibular disorders. A number of novel selective H4 antagonists are active in vestibular models in vivo. The preclinical potential of SENS-111 (Seliforant), an oral first-in-class selective H4 antagonist is the only such molecule to date to be translated into the clinical setting. With an excellent safety profile and notable absence of sedation, encouraging outcomes in an induced vertigo model in healthy volunteers have led to ongoing clinical studies in acute unilateral vestibulopathy, with the hope that H4 antagonists will offer new effective therapeutic options to patients suffering from vertigo.
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Bariatric Surgery Promising in Migraine Control: a Controlled Trial on Weight Loss and Its Effect on Migraine Headache. Obes Surg 2018; 28:87-96. [PMID: 28685361 DOI: 10.1007/s11695-017-2793-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
INTRODUCTION There is evidence that substantial weight loss through bariatric surgery (BS) may result in short-term improvement of migraine severity. However, it still remains to be seen whether smaller amounts of weight loss have a similar effect on migraine headache. This study has been designed to compare the effects of weight reduction through BS and non-surgical modifications. MATERIALS AND METHODS Migraine characteristics were assessed at 1 month before (T0), 1 month (T1), and 6 months (T2) after BS (vertical sleeve gastrectomy (VSG) (n = 25) or behavioral therapy (BT) (n = 26) in obese women (aged 18-60 years) with migraine headache. Migraine was diagnosed using the International Classification of Headache Disorders (ICHDIIβ) criteria. RESULTS There was significant reduction in the visual analog scale (VAS) from the baseline to T1 and T2 in both groups. The number of migraine-free days showed a significant increase within each group (p < 0.001). The BS group had a significant reduction in attack duration (p < 0.001) while there were no changes observed within the BT group. Following the adjustment of ANCOVA models for baseline values of migraine characteristics, age, changes in weight, BMI, body fat, and fat-free mass from T0 to T2, the BS group showed statistically significant lower VAS and duration of migraine attacks and a significantly higher number of migraine-free days than the BT group at T1 and T2 (p ≤ 0.028). CONCLUSION Our results indicated that far before significant weight reduction after BS (VSG), there was marked alleviation in the severity and duration of migraine and a significant increase in the number of migraine-free days in obese female migraineurs. However, the effects in the BT group were not comparable with the effects in the BS group.
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Liu F, Ma T, Che X, Wang Q, Yu S. The Efficacy of Venlafaxine, Flunarizine, and Valproic Acid in the Prophylaxis of Vestibular Migraine. Front Neurol 2017; 8:524. [PMID: 29075232 PMCID: PMC5641552 DOI: 10.3389/fneur.2017.00524] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 09/20/2017] [Indexed: 01/18/2023] Open
Abstract
Background Different types of medications are currently used in vestibular migraine (VM) prophylaxis, although recommendations for use are generally based on expert opinion rather than on solid data from randomized trials. We evaluated the efficacy and safety of venlafaxine, flunarizine, and valproic acid in a randomized comparison trial for VM prophylaxis. Methods Subjects were randomly allocated to one of three groups (venlafaxine group, flunarizine group, and valproic acid group). To assess the efficacy of treatment on vertigo symptoms, the following parameters were assessed at baseline and 3 months after treatment: Dizziness Handicap Inventory (DHI) scores, number of vertiginous attacks in the previous month, and Vertigo Severity Score (VSS). Adverse events also were evaluated. Results A decrease in DHI total scores was shown following treatment with all three medications, with no obvious differences between the groups. Treatment effects differed, however, in the DHI physical, functional, and emotional domains with only venlafaxine showing a decreased effect in all of three domains. Flunarizine and valproic acid showed an effect in only one DHI domain. Venlafaxine and flunarizine showed decreased VSS scores (p = 0 and p = 0.03, respectively). Although valproic acid had no obvious effect on VSS (p = 0.27), decreased vertigo attack frequency was observed in this group (p = 0). Venlafaxine also had an effect on vertigo attack frequency (p = 0), but flunarizine had no obvious effect (p = 0.06). No serious adverse events were reported in the three groups. Conclusion Our data confirm the efficacy and safety of venlafaxine, flunarizine, and valproic acid in the prophylaxis of VM, venlafaxine had an advantage in terms of emotional domains. Venlafaxine and valproic acid also were shown to be preferable to flunarizine in decreasing the number of vertiginous attacks, but valproic acid was shown to be less effective than venlafaxine and flunarizine to decrease vertigo severity. Trial registration ChiCTR-OPC-17011266 (http://www.chictr.org.cn/).
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Affiliation(s)
- Fenye Liu
- Department of Traditional Chinese Medicine, Shandong Provincial Hospital Affiliated to Shandong University, Jinan, China
| | - Tianbao Ma
- Department of Hearing Central, Women and Children's Health Care Hospital of Linyi, Linyi, China
| | - Xiaolin Che
- Department of Otolaryngology, Shandong Qianfoshan Hospital, Jinan, China
| | - Qirong Wang
- Department of Otolaryngology, Shandong Qianfoshan Hospital, Jinan, China
| | - Shudong Yu
- Department of Otolaryngology, Shandong Qianfoshan Hospital, Jinan, China
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Abstract
OPINION STATEMENT Vestibular migraine (VM) is a disorder with a spectrum of clinical presentations and among the most common causes of chronic vestibular symptoms. Some present with attacks before or during typical migraine, but many others have fluctuating or daily symptoms. While the symptoms and pathogenesis of vestibular migraine may have elements of both central and peripheral disorders, hearing loss should be absent. VM typically worsens with activity and head movements in general, and encompasses symptoms of vertigo, disequilibrium, or imbalance. While it is possible to confuse other disorders such as Meniere's disease with migraine, it is worth making the diagnosis of vestibular migraine on clinical grounds after ruling out other possible causes. For acute attack treatment, migraine-specific medications such as triptans may be effective. In patients with frequent or disabling attacks, preventive treatment is essential. Vestibular rehabilitation may be helpful as well as medications used for migraine prevention such as including propranolol, venlafaxine, topiramate, and amitriptyline. For refractory patients, use of acetazolamide or lamotrigine may be reasonable.
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Parella R, Babu SA. Pd(II)-Catalyzed, Picolinamide-Assisted, Z-Selective γ-Arylation of Allylamines To Construct Z-Cinnamylamines. J Org Chem 2017; 82:6550-6567. [DOI: 10.1021/acs.joc.7b00535] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Ramarao Parella
- Department of Chemical Sciences, Indian Institute of Science Education and Research (IISER) Mohali, Manauli P.O., Sector 81, SAS Nagar, Knowledge City, Mohali, Punjab 140306, India
| | - Srinivasarao Arulananda Babu
- Department of Chemical Sciences, Indian Institute of Science Education and Research (IISER) Mohali, Manauli P.O., Sector 81, SAS Nagar, Knowledge City, Mohali, Punjab 140306, India
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Vestibular Migraine: Clinical Challenges and Opportunities for Multidisciplinarity. Behav Neurol 2016; 2016:6179805. [PMID: 28082766 PMCID: PMC5204080 DOI: 10.1155/2016/6179805] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 10/05/2016] [Accepted: 10/31/2016] [Indexed: 12/13/2022] Open
Abstract
Migraine and vertigo are two very prevalent conditions in general population. The coexistence of both in the same subject is a significant clinical challenge, since it is not always possible to understand whether they are causally related or associated by chance, requiring different diagnostic and therapeutic approaches. In this review we analyze and summarize the actual knowledge about vestibular migraine (VM), focusing on the new concepts proposed by the International Classification of Headache Disorders 3-beta and by the Bárány Society and also addressing the former concepts, which are still present in clinical practice. We conclude that clinical studies using a multidisciplinary approach are crucial in this field, since different specialists observe the same pathology with different eyes. Clinical presentation of VM is variable in what concerns vestibular symptoms temporal relation with migraine headache, as well as in their accompanying manifestations. Biomarkers, either genomics or functional, and molecular imaging techniques will be helpful to clarify many aspects of the complexity of this entity, helping to define to what extent can VM be considered a separate and independent clinical entity.
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Recent Advances in the Understanding of Vestibular Migraine. Behav Neurol 2016; 2016:1801845. [PMID: 27821976 PMCID: PMC5086357 DOI: 10.1155/2016/1801845] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 09/05/2016] [Accepted: 09/20/2016] [Indexed: 01/03/2023] Open
Abstract
Approximately 1% of the general population and 10% of patients with migraine suffer from vestibular migraine (VM). However, this condition remains relatively unknown; therefore, it is often underdiagnosed despite the recent adoption of international diagnostic criteria for VM. The diagnosis of VM is based on the symptoms, degree, frequency, and duration of the vestibular episodes, a history of migraine, the temporal association of migraine symptoms with vestibular episodes in at least 50% of cases, and the exclusion of other causes. Physical examination and laboratory findings are usually normal in patients with VM but can be used to rule out other vestibular disorders with similar symptoms. The pathophysiology of VM remains incompletely understood; however, several mechanisms link the trigeminal system, which is activated during migraine attacks, and the vestibular system. Because few controlled trials have specifically investigated VM, the treatment options for this order are largely the same as those for migraine and include antiemetics for severe acute attacks, pharmacological migraine prophylaxis, and lifestyle changes.
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Barbosa F, Villa TR. Vestibular migraine: diagnosis challenges and need for targeted treatment. ARQUIVOS DE NEURO-PSIQUIATRIA 2016; 74:416-22. [DOI: 10.1590/0004-282x20160037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/29/2015] [Accepted: 01/13/2016] [Indexed: 01/03/2023]
Abstract
ABSTRACT Approximately 1% of the general population suffers from vestibular migraine. Despite the recently published diagnostic criteria, it is still underdiagnosed condition. The exact neural mechanisms of vestibular migraine are still unclear, but the variability of symptoms and clinical findings both during and between attacks suggests an important interaction between trigeminal and vestibular systems. Vestibular migraine often begins several years after typical migraine and has a variable clinical presentation. In vestibular migraine patients, the neurological and neurotological examination is mostly normal and the diagnosis will be based in the patient clinical history. Treatment trials that specialize on vestibular migraine are scarce and therapeutic recommendations are based on migraine guidelines. Controlled studies on the efficacy of pharmacologic interventions in the treatment of vestibular migraine should be performed.
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Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol 2016; 263 Suppl 1:S82-9. [PMID: 27083888 PMCID: PMC4833782 DOI: 10.1007/s00415-015-7905-2] [Citation(s) in RCA: 150] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 09/11/2015] [Accepted: 09/12/2015] [Indexed: 01/03/2023]
Abstract
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.
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Affiliation(s)
- Marianne Dieterich
- Department of Neurology, Ludwig-Maximilians University, Campus Grosshadern, Marchioninistr. 15, 81377, Munich, Germany.
- German Center for Vertigo and Balance Disorders, Ludwig-Maximilians University, Munich, Germany.
- Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.
| | - Mark Obermann
- Department of Neurology, University of Duisburg-Essen, Essen, Germany
- Center for Neurology, Asklepios Hospitals Schildautal, Seesen, Germany
| | - Nese Celebisoy
- Department of Neurology, Ege University Medical School, Bornova, Izmir, Turkey
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Lionetto L, Borro M, Curto M, Capi M, Negro A, Cipolla F, Gentile G, Martelletti P. Choosing the safest acute therapy during chronic migraine prophylactic treatment: pharmacokinetic and pharmacodynamic considerations. Expert Opin Drug Metab Toxicol 2016; 12:399-406. [DOI: 10.1517/17425255.2016.1154042] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Acetazolamide in vestibular migraine prophylaxis: a retrospective study. Eur Arch Otorhinolaryngol 2016; 273:2947-51. [PMID: 26728486 DOI: 10.1007/s00405-015-3874-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 12/22/2015] [Indexed: 01/03/2023]
Abstract
The aim of this study is to check the efficacy of acetazolamide in the prophylaxis of vestibular migraine (VM). Treatment options in VM are mainly based on migraine guidelines. We tried to assess the efficacy of acetazolamide in these patients depending on clinical similarities with episodic ataxia type 2 and familial hemiplegic migraine responding to the drug. This is a retrospective cohort study. Among 50 patients with VM and prescribed acetazolamide 500 mg/day, 39 patients were studied as five had been lost on follow-up and six had stopped taking the drug due to side effects. Vertigo and headache frequency determined by number of attacks per month, and the severity determined by visual analog scales measured in centimeters from 0 to 10 were collected from the records. Initial reported figures for frequency and severity were compared with the results gathered after 3 months of treatment. The results were compared. Acetazolamide was effective in reducing both the frequency and severity of vertigo and headache attacks and this effect was more prominent for vertigo frequency and severity.
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Fixed combination of cinnarizine and dimenhydrinate in the prophylactic therapy of vestibular migraine: an observational study. Neurol Sci 2015; 36:1869-73. [PMID: 26037548 DOI: 10.1007/s10072-015-2270-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 05/27/2015] [Indexed: 01/03/2023]
Abstract
Vestibular migraine (VM) is one of the most frequent causes of episodic vertigo, with a lifetime prevalence of 0.98%. Prophylactic therapy includes calcium channel blockers, beta-blockers, antiepileptic drugs and antidepressants. We studied the association of cinnarizine 20 mg and dimenhydrinate 40 mg (Arlevertan) in a group of 22 patients affected by definite VM. Proposed therapy included one tablet twice a day for 1 month, which was repeated three times with 1 month of interval between drug intake; results were compared with those of a control group of 11 VM patients who asked to observe only lifestyle measures for migraine. The main outcome was the number of vertigo and headache crises in the 6 months before therapy and in the 6 months of follow-up. Subjects performing Arlevertan presented during the 6 months of therapy a decrease of vertigo attacks from 5.3 to 2.1 and of headaches from 4.3 to 1.7 (p < 0.0001); 68% of these subjects reported a decrease of at least 50% of vertigo attacks, while 63% of headaches. Conversely, vertigo attacks decreased from 3.5 to 2.2 and headaches from 2.6 to 2 in patients observing only lifestyle; 18% of these subjects reported a decrease of at least 50% of vertigo crises and 27% of headaches. Our data do not differ from those of previous works assessing efficacy of different prophylactic therapies for VM and reporting consistent reduction of vertigo spells in a rate of patients ranging from 60 and 80%.
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Recent advances in delivery systems and therapeutics of cinnarizine: a poorly water soluble drug with absorption window in stomach. JOURNAL OF DRUG DELIVERY 2014; 2014:479246. [PMID: 25478230 PMCID: PMC4247907 DOI: 10.1155/2014/479246] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Accepted: 10/15/2014] [Indexed: 11/18/2022]
Abstract
Low solubility causing low dissolution in gastrointestinal tract is the major problem for drugs meant for systemic action after oral administration, like cinnarizine. Pharmaceutical products of cinnarizine are commercialized globally as immediate release preparations presenting low absorption with low and erratic bioavailability. Approaches to enhance bioavailability are widely cited in the literature. An attempt has been made to review the bioavailability complications and clinical therapeutics of poorly water soluble drug: cinnarizine. The interest of writing this paper is to summarize the pharmacokinetic limitations of drug with special focus on strategies to improvise bioavailability along with effectiveness of novel dosage forms to circumvent the obstacle. The paper provides insight to the approaches to overcome low and erratic bioavailability of cinnarizine by cyclodextrin complexes and novel dosage forms: self-nanoemulsifying systems and buoyant microparticulates. Nanoformulations need to systematically explored in future, for their new clinical role in prophylaxis of migraine attacks in children. Clinical reports have affirmed the role of cinnarizine in migraine prophylaxis. Research needs to be dedicated to develop dosage forms for efficacious bioavailability and drug directly to brain.
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Obermann M, Strupp M. Current treatment options in vestibular migraine. Front Neurol 2014; 5:257. [PMID: 25538676 PMCID: PMC4255594 DOI: 10.3389/fneur.2014.00257] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 11/21/2014] [Indexed: 01/03/2023] Open
Abstract
Approximately 1% of the general population in western industrialized countries suffers from vestibular migraine. However, it remains widely unknown and often under diagnosed despite the recently published diagnostic criteria for vestibular migraine. Treatment trials that specialize on vestibular migraine are scarce and systematic randomized controlled clinical trials are now only emerging. This review summarizes the knowledge on the currently available treatment options that were tested specifically for vestibular migraine and gives an evidence-based, informed treatment recommendation with all its limitations. To date only two randomized controlled treatment trials provide limited evidence for the use of rizatriptan and zolmitriptan for the treatment of vestibular migraine attacks because of methodological shortcomings. There is an ongoing multicenter randomized placebo-controlled trial testing metoprolol 95 mg vs. placebo (PROVEMIG-trial). Therefore, the therapeutic recommendations for the prophylactic treatment of vestibular migraine are currently widely based on the guidelines of migraine with and without aura as well as expert opinion.
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Affiliation(s)
- Mark Obermann
- Department of Neurology, Vertigo and Dizziness Center, University of Duisburg-Essen , Essen , Germany
| | - Michael Strupp
- Department of Neurology, German Center for Vertigo and Balance Disorder, Ludwig-Maximillians-University Munich , Munich , Germany
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