Migrainous Vertigo

Dr Mark Lewis

MY NsC

Migrainous VertigoOutline

• Case studies• (Migraine)• Terminology• Pathophysiology• Epidemiology• Clinical features• Investigations• Differential diagnosis• Treatment

Case 1

• 48y, female, 10 year history• Attacks of vertigo lasting hours to days

• Associated hearing change• Bilateral tinnitus

• Positional symptoms• In between, sense of disequilibrium• PMHx, depression, anxiety

Case 1

• S/B ENT, psychiatry, cardiology, neurology• Diagnosed with Meniere’s, BPPV &

anxiety• Ix

• Mild SN hearing loss• Normal MRI

Case 2

• 72y, female, 20 year history• Episodic attacks of dizziness• More recently, constant bobbing - “boat”• PMHx, diabetes

Case 2

• S/B ENT, elderly medicine, neurology• Diagnosed with Labyrinthitis & later

Meniere’s• Ix

– Moderate asymmetrical hearing loss– MRI - normal

Case Studies

• Case 1• Meniere’s• BPPV• Anxiety

• Case 2• Labyrinthitis• Meniere’s

• Happy?• TBC

Migrainous VertigoOutline

• Case studies• (Migraine)• Terminology• Pathophysiology• Epidemiology• Clinical features• Investigations• Differential diagnosis• Treatment

Migraine

• 8-13% prevalence (~80% without aura)• female predominance (~2:1)• 5% of men at all ages• 10% of women at menarche

– 30% peak at ~35yrs

Migraine

• IHS criteria• A. At least 5 attacks fulfilling B-D• B. Headache attacks lasting 4-72 hours• C. Headaches having at least 2 of the following:

» Unilateral location» Pulsating quality» Moderate or severe intensity» Aggravated by physical activity

• D. No other diagnosis to explain the headache

– Remember – research criteria!

Migraine pathophysiology

Migrainous Vertigo

– Terminology• Migraine associated vertigo• Migraine-related vestibulopathy• Vestibular migraine• Benign recurrent vertigo• Basilar type migraine (?other symptoms)• (Benign paroxysmal vertigo of childhood)• etc

Vestibular Migraine

– Terminology• Migrainous vertigo• Migraine associated vertigo• Migraine-related vestibulopathy• Benign recurrent vertigo• Basilar type migraine (?other symptoms)• (Benign paroxysmal vertigo of childhood)• etc

Vestibular Migraine

• Pathophysiology• Uncertain• ?hypoperfusion of the labyrinth• ?Spreading depression – vestibular cortex

» ?complex nystagmus not explained by this

• ?neurotransmitter release• ?ion channels

– Now brainstem up (like migraine itself)– “Sensitivity sysndrome”

VM pathophysiology

Vestibular Migraine

– Epidemiology– Menieres 0.2% v migraine ~13%– Migraine over represented in patients with:

» BPPV ~50% in those <50y» Menieres ~50%» & vice-versa

– “Migraine” clinics» 27-42% report episodic vertigo» Of these 36% vertigo in headache free period (rest

just before or during)– “Dizzy” clinics

» 16-32% have migraine– Motion sickness ~50% of migraine sufferers (cf ~5-20%)

Vestibular Migraine

– Epidemiology (contd)– Commonest cause of recurrent spontaneous vertigo– Second commonest vestibular disorder in specialist

clinics (5-10%)

Vestibular Migraine

– Clinical features• Attacks of variable duration

– Spontaneous vertigo– Positional vertigo– Head motion intolerance / discomfort– ?Migrainous symptoms

» Headache» Photophobia / phonophobia etc» Aura» Precipitants (foods, poor sleep, hormonal, etc, etc)» “Soft markers”

» Undeserved hangovers, motion sensitivity, yawning, neck ache, visual vertigo, MDD etc

Vestibular Migraine

– History• Need to ask specifically• ?Dizziness diary (for precipitants etc)• Different to aura of a migraine

– Few seconds to weeks!» 20-30% have attacks lasting 5-60 mins (ie aura like)» 50-70% attacks for hours or days» Can fluctuate

• Cochlear symptoms ?10-40%» Hearing loss, tinnitus, aural fullness! (mild and non-

progressive)

Vestibular Migraine

– Examination• Usually normal between attacks

» (Repeated) attacks can cause vestibular damage

• During attack» ? All types of nystagmus» Ataxia» Others

Vestibular Migraine

• Barany Society – IHS Criteria• VM

– A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours

– B. Migraine current or previous (IHS criteria)– C. At least one of the following symptoms during at least 50% of

the vertiginous attacks:» Migrainous headache» Photophobia» Phonophobia» Visual aura

– D. Not better accounted for by another vestibular or ICHD diagnosis

Vestibular Migraine

• Barany Society – IHS Criteria• Probable VM

– A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours

– B. Either or PMHx of migraine or migrainous features during episode

– C. Not better accounted for by another vestibular or ICHD diagnosis

– Remember – Research criteria!!

– Chronic VM??– “on a boat”, “swaying”, constantly off balance with

exacerbations, etc

Vestibular Migraine

• Investigations• Audiometry• First attack – probably imaging• (?Nystagmography)• (?VEMPs)• (??Otoacoustic emission suppression)

Vestibular Migraine

• Differential diagnosis• Non-specific migrainous “dizziness”

» ?postural hypotension» ?other

• Meniere’s» Duration of attacks» Progression of hearing loss» Very “migrainous => migraine» Very “menieres” => menieres

Vestibular Migraine

• Differential diagnosis• POCS TIAs

» Presence of migrainous features» Lack of risk factors» Young age» Long attacks with complete recovery» Frequent attacks with no “stroke”» Long history of attacks with no “stroke”

• Vestibular paroxysmia» Very short» Daily occurrence» High frequency» Response to CBZ

• Other neurological disorders (EA, cerebellar etc)• ?(“Cervical vertigo”)

Vestibular Migraine

• Treatment• EXPLANATION• Avoidance of triggers• Acute

» Analgesics» Pro-kinetic anti-emetics» Vestibular sedatives» Migraine specific treatments (Rizatriptan)

Vestibular Migraine

• Treatment– Prophylaxis

• Frequent or prolonged attacks (or chronic)– Usual

» Amitriptyline» Propranalol» Pizotifen» Topiramate» Na Valproate» Lamotrigine» etc

Case Studies

• Case 1• Meniere’s• BPPV• Anxiety

• Case 2• Labyrinthitis• Meniere’s

Case Studies

• Case 1• Meniere’s• BPPV• Anxiety

• Case 2• Labyrinthitis• Meniere’s

• ? Either / both / neither - VM

Three Things

• BPPV• VM• Uncompensated vestibular dysfunction

– eg previous VN, on stemetil for 20 years!!