Some aspects of episodic giddiness

Spinning Through History: Evolution of the Concept of Vestibular Migraine

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

Medical management of migraine-related dizziness and vertigo

Historically, review of migraine-related vestibular symptoms has focused on the various clinical presentations that occur and the results of diagnostic studies of vestibular function. Treatment of vestibular symptoms related to migraine has been proposed similar to that used for headache control, but few examples of the effectiveness of this therapy have been published. The purpose of this study is to present the various approaches that can be used to manage vestibular symptoms related to migraine, and to evaluate the overall effectiveness of these treatment approaches. This was a retrospective review of 89 patients diagnosed with migraine-related dizziness and vertigo. The character of vestibular symptoms, pattern of cochlear symptoms, results of auditory and vestibular tests, and comorbidity factors are presented. Treatment was individualized according to symptoms and comorbidity factors, and analyzed regarding effectiveness in control of the major vestibular symptoms of episodic vertigo, positional vertigo, and nonvertiginous dizziness. Medical management included dietary changes, medication, physical therapy, lifestyle adaptations, and acupuncture. Complete or substantial control of vestibular symptoms was achieved in 68 (92%) of 74 patients complaining of episodic vertigo; in 56 (89%) of 63 patients with positional vertigo; and 56 (86%) of 65 patients with non-vertiginous dizziness. Similarly, aural fullness was completely resolved or substantially improved in 34 (85%) of 40 patients; ear pain in 10 (63%) of 16 patients; and phonophobia in 17 (89%) of 19 patients. No patient reported worsened symptoms following medical management. The conflicting concept of a central disorder (migraine) as the cause of cochlear and vestibular dysfunction that often has peripheral features is discussed.

Migraine-associated vertigo

A retrospective analysis was performed on a consecutive series of 363 patients presenting with vertigo; 32% had migraine. Of the 224 patients with no pathology other than migraine or vestibular dysfunction, migraineurs had a significantly higher prevalence of normal, central, and combined central and peripheral vestibular dysfunction compared to non-migraineurs. The combination of central and peripheral vestibular signs was a feature of migraine with aura. The results support the hypothesis that migraine-associated vertigo is a diagnostic entity.

Benign recurrent vertigo

Patients with recurrent vertigo in the absence of cochlear signs remain a diagnostic problem. The absence of a standard system of nomenclature further hampers the understanding of these disorders. The term benign recurrent vertigo is suggested as a useful term to characterise many of these patients. The disorder shares some of the features of migraine, and seems likely to have a similar vasospastic aetiology.

[Migraine and the vestibular apparatus (author's transl)]

Thirty patients with simple or ophthalmic migraine had an otoneurological examination. 13% complained of vertigo during attacks of migraine, 17% of giddiness and 6.7% of tinnitus. The usual tests for equilibrium were normal. On electronystagmographical examination 17% of the patients showed only pathological spontaneous nystagmus, 33% only disturbances of caloric response and 7% a combination of both. Audiological testing was normal. The incidence of vestibular disturbances, particularly sensitivity differences of the labyrinths, was significantly greater in the group of patients with migraine than in a control group of 30 healthy persons (P less than or equal to 0.025). On the average, the sensitivity differences, in terms of duration of reactive nystagmus, were greater for these than for the healthy persons (P less than or equal to 0.01). Patients with vestibular disturbances did not show a greater frequency of pathological EEG readings than patients with normal vestibular function. Some hypotheses concerning the pathogenesis of vestibular symptoms as found in migrainous patients are mentioned.