Episodic Vertigo? Consider and Treat as Vestibular Migraine
By Dara G. Jamieson, MD
Emeritus Associate Professor of Clinical Neurology, Weill Cornell Medical College
Dr. Jamieson reports no financial relationships relevant to this field of study.
SYNOPSIS: Vertigo is a common and integral component of migraine and occurs with neuro-otologic abnormalities and psychiatric comorbidities. Treatment of episodic vertigo suspected to be due to vestibular migraine should mirror the multimodality treatment of migraine.
SOURCES: Beh SC, Masrour S, Smith SV, Friedman DI. The spectrum of vestibular migraine: Clinical features, triggers, and examination findings. Headache 2019;59:727-740.
Lampl C, Rapoport A, Levin M, Brautigam E. Migraine and episodic vertigo: A cohort survey study of their relationship. J Headache Pain 2019;20:33.
Lapira A. Vestibular migraine treatment and prevention. HNO 2019;67:425-428.
Beh et al published a retrospective chart review of 131 patients (105 women) with vestibular migraine (VM) seen at the University of Texas Southwestern Medical Center Vestibular & Neuro-Visual Disorders Clinic from August 2014 until March 2018. The 2012 International Headache Society — Bárány Society definition of VM used for the diagnosis is essentially a migraine with vestibular symptoms such as vertigo, dizziness, visually induced or head-motion vertigo/dizziness, positional vertigo, oscillopsia, visual lag, and postural symptoms. The mean age at onset of VM was 44.3 (± 13.7) years. Prior to developing vestibular symptoms, most with VM had a history of migraine (57.3%) and motion sickness (61%). About half of patients with a VM diagnosis developed migraine and vertigo concurrently. A known family history of migraine (51%), especially with vertiginous features, and episodic vestibular symptoms (28%) were common. Vestibular migraine triggers were similar to known migraine triggers and included stress, bright lights, change in weather, and sleep deprivation. Common ictal symptoms were vertigo with photophobia, phonophobia, nausea, aural symptoms (e.g., tinnitus, ear fullness, muffled hearing), and headache. Vestibular migraine was associated with “Alice in Wonderland” syndrome of dysperceptions with extrapersonal misperceptions (e.g., out-of-body experience, derealization) and visual distortions in 7% and somesthetic distortions in 3% of those with VM. The majority of VM patients experienced dizziness between migraine attacks triggered by vision (89%) or head motion (66%), and 51% of patients with VM reported persistent dizziness. Anxiety (70%) and other psychiatric comorbidities were common: depression (40%), insomnia (29%), phobias (11%), and psychogenic disorders (8%). The interictal neuro-otologic examination was abnormal in 43%, usually manifesting as nystagmus induced by hyperventilation, head-shaking, vibration, or position. Although gait and conventional Romberg testing usually were normal, the sharpened Romberg test (standing with feet tandem with eyes open and then eyes closed) was abnormal in 17% of patients. Brain imaging was normal or revealed incidental, unrelated findings.
Lampl et al investigated the common co-occurrence of migraine headache and vestibular-type episodic vertigo (eV) using data from 487 adult participants in a questionnaire-based survey (“Migraine and Neck Pain Study”). Almost one-third of the total migraine participants (73% female, mean age 38 years) reported eV anytime during the migraine attack: 3% in the premonitory phase, 10% within two hours prior to the headache, and 16% at the start of the headache. Episodic vertigo did not disproportionately affect patients with migraine with aura (25%) compared with migraine without aura (31%). The authors concluded that “the symptom of eV is more of a headache phase phenomenon, rather than prodromal.” They predicted that eV episodes can be shown to satisfy the diagnostic criteria for VM.
In a review of the diagnosis and treatment of VM, Lapira wrote that VM probably represents the second most common cause of vertigo after benign positional vertigo and is the most common cause of eV. The symptomatic overlap between VM and the less common Ménière’s disease include episodic vertigo, sensorineural hearing loss, and tinnitus. Lapira stated that VM is associated with more prolonged vertigo and imbalance than Ménière’s disease. Other symptoms pointing toward VM included: photo- or phonophobia; non-progressive sensorineural hearing loss; and a history of motion intolerance, dizziness around the menstrual cycle, and/or childhood benign positional vertigo. The coexistence of VM and anxiety is established with an acronym “MARD” (migraine–anxiety-related dizziness). Treatments for VM include diet and behavior modification; abortive migraine medications; migraine preventive medication such as low-dose tricyclic antidepressants, calcium channel blockers, beta-blockers, or topiramate; and vestibular rehabilitation.
Vertigo and dizziness are especially frustrating symptoms for clinicians to treat and patients to endure because of their debility, subjective nature, and lack of distinct diagnostic markers or specific effective therapies. However, if the linkage between vertigo/dizziness and migraine is recognized, especially in middle-aged women in whom VM is more prevalent, then migraine treatment approaches may prevent episodic vertigo/dizziness, with or without other migraine symptomatology.
Beh et al noted that the varied and somewhat bizarre nature of the complaint in patients with VM may seem to point to a purely psychiatric etiology and that, “It is therefore vital for clinicians to recognize the clues that can help them correctly diagnose and treat this common disorder.” The realization of a vertigo/dizziness-migraine connection can dispel the tendency to trivialize the sensation, which may occur especially when the patient’s description is of a nonspecific or vaguely categorized dizziness, as opposed to the more validated description of vertigo. The correlating abnormalities found on neurological examination, including the sharpened Romberg test, as described by Beh et al, are helpful in establishing the diagnosis of VM, without resorting to brain imaging that is likely to be unrevealing. Lampl et al proposed that vertigo should join the environmental sensitivities to light, sound, and smell as a symptom integrated into the headache itself. An analogy could be made that vertigo is sensitive to environmental movement. Whether the abnormal sensation associated with migraine is premonitory, aura-related, or integral is of academic but not practical interest, as complaints of vertigo/dizziness, either episodic or chronic, should initiate patient-directed questions related to migraine phenomena, with the goal of migraine-directed treatment if an association is found. If you hear episodic “vertigo” or “dizziness,” consider migraine.
Vertigo is a common and integral component of migraine and occurs with neuro-otologic abnormalities and psychiatric comorbidities. Treatment of episodic vertigo suspected to be due to vestibular migraine should mirror the multimodality treatment of migraine.
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