Adapted from lecture handout given for the seminar "Recent advances in the treatment of Dizziness", American Academy of Neurology, 1997 and "Migraine Vs Meniere's", at the American Academy of Otolaryngology meeting, 1999-2001.
Last edited: 2/2003
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Timothy C. Hain, MD, Chicago IL.
Dizziness and headache are individually very common human conditions and their combination is also a common symptom complex. Diagnostically, one must determine whether the dizziness and headaches are independent or related to each other, and in particular, whether they are a manifestation of migraine. Here we will review the association between vertigo and migraine. This subject has also been recently reviewed by Reploeg and Goebel (2002) as well as Radke et al (2002).
Nearly 13% of the adult population of the United States has migraine. There is a male-female distribution difference. At all ages, about 5% of men have migraine (Stewart, 1994; Lipton et al, 2002). Women of childbearing age have a much higher prevalence, jumping up to roughly 10% at the onset of menstruation, and increasing to nearly 30% at the peak age of 35 years. At menopause, rates of migraine abruptly decline in women back to roughly 10%. The prevalence of Migraine is far higher than that of Meniere's disease, which occurs in only 0.2% of the US population (Wladislavosky-Waserman et al, 1984). In a small study of persons with Menieres disease, the prevalence of Migraine was about 50%, compared with a figure of about 25% in the non-Meniere's population (Radke et al, 2002). Other studies have shown different results however. There have also been recent studies showing that there is a higher frequency of BPPV in persons with Migraine (Ishiyama et al, 2000), and almost half of persons with BPPV onset before the age of 50 meet criteria for migraine.
|Table 1: Patients with Migraine having Vertigo|
|Percent of migraine patients with vertigo||Comment||Authors|
|26.5 %||Unsolicited migraine (n=200)||Kayan and Hood (1984)|
|33 %||Selby and Lance (1960)|
|42 %||Migraine with aura||Kuritzky et al (1981)|
In practices focused on treating migraine, 27-42 % of patients report episodic vertigo (See table 1). A large number (about 36%) of these patients experienced vertigo during headache-free periods. The remainder experienced vertigo either just before or during the headache. The incidence of vertigo during the headache period was higher in patients with aura as opposed to in those without aura.
In practices focused on treating vertigo, 16-32% of patients have migraine (Savundra et al, 1997). The prevalence of migraine in the general population is 10% (Stewart et al, 1994).
|Table 2: Patients with Migraine having Motion Sickness|
|Percent of migraine patients with motion sickness||Comment||Authors|
|45%||Children (60)||Barabas et al (1983)|
|50.7%||Unselected||Kayan and Hood (1984)|
Motion sickness is a common migraine accompaniment. Most studies report about 50% of patients with migraine have motion sickness, compared to about 5-20% for control groups.
Syncope can also accompany migraine, and this offers another entirely separate mechanism. In migraine, hypotension is likely hormonal, and is attributed mainly to vasopressin (Gupta, 1997).
|Fortification spectra, as might be seen in Migraine with aura.||Scotoma with aspects of a fortification.|
Migraine without aura (about 80%) and migraine with aura (about 15-20%) are the most prevalent forms of migraine and also are the most prevalent types of migraine associated with dizziness and vertigo. Symptoms include true vertigo with or without nausea and vomiting, and motion intolerance. Headache is usual but not required (see following). Auditory symptoms are common but usually bilateral (see following). Hyperacusis is common in migraine, which may differentiate it from most ear disorders. Sensitivity to light (photophobia) is also commonly present.
When patients are examined acutely when vertiginous, there is usually minimal or no spontaneous nystagmus. This provides a differential feature from most peripheral vestibular syndromes. When nystagmus is present, it is often directed vertically (e.g. upbeating or downbeating). Vertically directed spontaneous nystagmus is unusual in other contexts, providing another differential point.
Timing. Cutrer and Baloh (1992) found a bimodal distribution of duration of vertigo with 31% of individuals having spells that typically lasted a few minutes to 2 hours and 49% having spells that lasted longer than 24 hours. Therefore by duration, these episodes could be confused with those due to BPPV, Menieres, or even vestibular neuritis.
Headache is not required to make the diagnosis of MAV. As in migraine, occasionally aura may occur without headache (acephalgic migraine), it also follows that vertigo may occur without headache. Benign recurrent vertigo of adults, essentially a vertiginous migraine aura without headache, was described first by Slater (1979). It consists of spells of vertigo, which can include tinnitus, but without hearing loss (were hearing loss allowed, this disorder would become very difficult to distinguish from Menieres). Vertigo lasts from minutes to hours. Not all authors agree that BRV is caused by migraine however, and Leliever and Barber suggested that it is caused by peripheral vestibular lesions (Leliever WC, Barber HO. Recurrent vestibulopathy. Laryngoscope 1981:91:1-6). Another example is the Benign Paroxysmal Vertigo syndrome of children, as described below under the heading of familial syndromes, where headache does not occur. Cutrer and Baloh (1992) also observed that dizziness and headaches are not necessarily closely associated. In fact, in their 91 patients, only 5 had a consistent recurring dizziness with headache. In 30%, dizziness was consistently independent of headache. In most, spells sometimes occurred with and sometimes independently.
Basilar Migraine, also known as Bickerstaff s syndrome(1961), consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields of both eyes, diplopia, bilateral paresthesias or paresis, decreased LOC) followed by a throbbing headache. Vertigo typically lasts between 5 minutes and one hour. In the authors practice, the typical patient is a woman of about 35 years of age, who attacks of vertigo combined with headache. The family history is often positive. In the differential are TIAs and paroxysmal vestibular disorders accompanied by headache. Patients usually respond diet or the usual prophylactic drugs.
Auditory symptoms are rare compared to vestibular symptoms but nevertheless there is good evidence that hearing loss and tinnitus do occur. Olsson (1991) in a study of 50 patients with basilar migraine (which is rare) documented a fluctuating low-tone sensorineural hearing loss in more than 50% of his patients, and about 50% of his patients noticed a change in hearing immediately prior to their migraine headaches. Virre and Baloh (1996) suggested that sudden hearing loss may also be caused by migraine. Tinnitus is also common in migraine (Kayan and Hood, 1984; Olsson, 1991). Because the formal criteria for Menieres disease (audiometrically documented hearing loss (not fluctuation), episodic tinnitus and/or fullness, episodic vertigo) are a subset of the documented spectrum of basilar migraine, there is the possibility for diagnostic ambiguity (Harker, 1996). Boismier and Disher reported that 6% of 770 patients who presented with vertigo fell into an ambiguous diagnostic situation between Meniere's and Migraine (2002). When headache is not prominent, features such as bilateral hearing fluctuation (according to Harker (1996) auditory symptoms are rarely unilateral), family history of migraine and perimenstrual exacerbations are used to decide whether Menieres or migraine is the more likely diagnosis.
Benign Paroxysmal Vertigo of Childhood, is a disorder of uncertain origin, possibly migrainous. It's initials (BPV) are easily confused with those of Benign Paroxysmal Positional Vertigo (BPPV), but it is not caused by the same mechanisms. This disorder consists of spells of vertigo and disequlibrium without hearing loss or tinnitus (Basser, 1964). The majority of reported cases occur between 1 and 4 years of age, but this syndrome seems indistinguishable from benign recurrent vertigo (BRV, see following) in adults which is presently attributed to migraine, or so-called "vestibular Menieres", which is also attributed to migraine. The differential diagnosis includes Menieres disease, vestibular epilepsy, perilymphatic fistula, posterior fossa tumors, and psychogenic disorders.
Familial syndromes: There has recently been a report of a familial vestibulopathy, called familial Benign Recurrent Vertigo (BRV) consisting of episodic vertigo with or without migraine headache. Presumably there are both familial and nonfamilial forms -- fBRV and BRV. The non-familial form is sometimes called recurrent vestibular neuritis as well as vestibular menieres.
Vestibular testing in the familial form can document profound bilateral vestibular loss. The familial syndrome responds to acetazolamide (Baloh et al, 1994). It is not associated with a mutation on the calcium channel gene (Oh et al, 2001). Also reported by Baloh and associates, a form exists with episodic vertigo and essential tremor. This form is also responsive to acetazolamide. (Baloh et al, 1996). Familial hemiplegic migraine has been linked to mutations in the calcium channel gene (Ophoff et al, 1996). French-Canadian intermittent ataxia syndrome also may present similarly. While no mutations have been identified in the common form of migraine, calcium channels could be functionally impaired by subtle gene changes such as polymorphisms.
Antiphospholipid antibodies. While controversial, there are some reports that individuals with severe migraine headaches are more likely to have antiphospholipid antibodies. In the authors experience, these patients may present with transient monocular visual loss, and some also have fetal wastage and complicated migraines. (Donders et al, 1998)
Treatment of MAV. For treatment of migraine in general see this page. Because of the possibility for serious injury associated with vertigo, prevention is the advised treatment for most types of MAV. Eliminating triggers and prophylactic treatment are the modalities used most frequently. Patients are initially told to abstain from foods such as chocolate, cheese, alcohol and MSG containing preparations. If this is not successful, after a month, patients are started on verapamil, a long-acting beta-blocker such as long acting propranolol, or amitriptyline depending on gender and situation. Verapamil and amitriptyline are particularly useful because of their anticholinergic properties may help control vertigo independently of whether they are useful for migraine per se.