Subjective and objective responses to caloric stimulation help separate vestibular migraine from other vestibular disorders

BACKGROUND

Nystagmus generated during bithermal caloric test assesses the horizontal vestibulo-ocular-reflex. Any induced symptoms are considered unwanted side effects rather than diagnostic information.

AIM

We hypothesized that nystagmus slow-phase-velocity (SPV) and subjective symptoms during caloric testing would be higher in vestibular migraine (VM) patients compared with peripheral disorders such as Meniere's disease (MD) and non-vestibular dizziness (NVD).

METHODS

Consecutive patients (n = 1373, 60% female) referred for caloric testing were recruited. During caloric irrigations, patients scored their subjective sensations. We assessed objective-measures, subjective vertigo (SVS), subjective nausea (SNS), and test completion status.

RESULTS

Nystagmus SPV for VM, MD (unaffected side), and NVD were 29 ± 12.8, 30 ± 15.4, and 28 ± 14.2 for warm irrigation and 24 ± 8.9, 22 ± 10.0, and 25 ± 12.8 for cold-irrigation. The mean SVS were 2.5 ± 1.1, 1.5 ± 1.33, and 1.5 ± 1.42 for warm irrigation and 2.2 ± 1.1, 1.1 ± 1.19, and 1.1 ± 1.16 for cold-irrigation. Age was significantly correlated with SVS and SNS, (p < 0.001) for both. The SVS and SNS were significantly higher in VM compared with non-VM groups (p < 0.001), and there was no difference in nystagmus SPV. VM patients SVS was significantly different to the SVS of migraineurs in the other diagnostic groups (p < 0.001). Testing was incomplete for 34.4% of VM and 3.2% of MD patients. To separate VM from MD, we computed a composite value representing the caloric data, with 83% sensitivity and 71% specificity. Application of machine learning to these metrics plus patient demographics yielded better separation (96% sensitivity and 85% specificity).

CONCLUSION

Perceptual differences between VM and non-VM patients during caloric stimulation indicate that subjective ratings during caloric testing are meaningful measures. Combining objective and subjective measures could provide optimal separation of VM from MD.

Dissociation of caloric and head impulse tests: a marker of Meniere's disease

A retrospective analysis of the horizontal video head impulse test (vHIT) results and caloric testing results was undertaken on 644 patients who attended a neuro-otology outpatient facility. Presenting symptoms included spontaneous vertigo, positional vertigo, imbalance or chronic subjective dizziness. For 570 patients, the results of vHIT and caloric testing were concordant. Both tests were normal in 500 subjects with an average vHIT gain = 0.92 ± 0.09 (L); 0.98 ± 0.10 (R) and canal paresis (CP) = 7.88 ± 6.12; (range 0-28%). 54 had concordant asymmetries, average ipsilesional vHIT gain = 0.56 ± 0.15, average contralesional vHIT gain = 0.88 ± 0.12. CP = 68.02 ± 24.38 (range 31-100%). 16 subjects had bilateral vestibular hypofunction with average vHIT gains of 0.42 ± 0.20 (L); 0.41 ± 0.19 (R), peak slow phase velocity (SPV) on warm caloric testing = 2.68 ± 2.08, range 0-6°/s (L) and 3.75 ± 3.43 range, 0-10°/s (R). 36 patients showed a dissociation of results between the two tests. In these subjects, the vHIT gain was normal (0.93 ± 0.06 left and 0.98 ± 0.07 right) and the caloric test showed a CP > 30% (48 ± 13.8%). Their final diagnoses included clinically definite Meniere's disease (MD) (n = 27), vestibular schwannoma (VS) (n = 2) vestibular migraine (VM) (n = 1), vestibular neuritis (VN) (n = 5) and unknown (n = 1). No patient with abnormal HSCC gain on vHIT had a normal caloric result. The caloric test complements the vHIT in the assessment of vestibular disorders and is most useful in suspected endolymphatic hydrops. Asymmetric caloric function in the presence of normal horizontal head impulse tests is most commonly associated with Meniere's disease and may function as a diagnostic marker.

Semicircular canal plane head impulses detect absent function of individual semicircular canals

We studied the human vestibulo-ocular reflex (VOR) in response to head 'impulses': brief, unpredictable, passive, high-acceleration (up to 4000 degrees/s2), low-amplitude (20-30 degrees) head rotations. We delivered the head impulses approximately in the plane of the semicircular canal (SCC) being tested. To test the anterior and posterior SCCs, the head impulses were delivered in a diagonal plane, midway between the frontal (roll) and sagittal (pitch) planes. We recorded head and eye position in three dimensions with scleral search coils in nine normal subjects, seven patients following unilateral surgical vestibular neurectomy and three patients following unilateral posterior SCC occlusion. In the post-surgical patients we demonstrated a severe, permanent VOR gain deficit (0.2-0.3) for head impulses directed toward any single non-functioning SCC. The sensitivity of the test depends on the physiological properties of primary vestibular afferents, and its specificity depends on the anatomical orientation of the SCCs. The diagonal head impulse is the first test of individual vertical SCC function in humans, and together with the horizontal head impulse, forms a comprehensive battery of SCC-plane tests. These canal-plane impulses could be useful in evaluating patients with vertigo or other vestibular disorders.