Migraine-associated vertigo
Encyclopedia
Migraine-associated vertigo (MAV) is vertigo
associated with a migraine
, either as a symptom of migraine or as a related but neurological disorder
; when referred to as a disease
unto itself, it is also termed vestibular migraine, migrainous vertigo, or migraine-related vestibulopathy.
A 2010 report from the University of British Columbia
published in the journal Headache
said that it "... is emerging as a popular diagnosis for patients with recurrent vertigo. Even though some authors believe that 'migraine associated vertigo,' is neither clinically nor biologically plausible as a migraine variant." Epidemiological studies leave no doubt that there is a strong link between vertigo and migraine.
- Migraine is commonly associated with BPPV, the most common vestibular disorder in patients presenting
with dizziness. The two may be linked by genetic factors or by vascular damage to the labyrinth.
Ménière’s disease - There is an increased prevalence of migraine in patients with Ménière’s disease and migraine leads to a greater susceptibility of developing Ménière’s disease. But they can be distinguished. Migraine-associated vertigo may go on for days or even years, while Ménière’s disease never goes on longer than 24 hours.
Motion sickness is more prevalent in patients with migraine.
Psychiatric syndromes Dizziness and spinning vertigo are the second most common symptom of panic attack
s, and they can also present as a symptom of major depression. Migraine is a risk factor for developing major depression and panic disorder and vice versa.
disturbance. It may include a feeling of rotation or illusory sensations of motion or both. The general term dizziness is used by nonmedical people for those symptoms but often refers to a feeling of light-headedness, giddiness, drowsiness, or faintness, all of which must be differentiated from true vertigo, since the latter symptoms might have other causes.
Motion sickness occurs more frequently in migraine patients (30-50%) than in controls. Benign paroxysmal vertigo of childhood is an example of migraine-associated vertigo in which headache does not often occur. Basilar migraine consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia
, dysarthria
, visual symptoms in both hemifields or both eyes, diplopia
, bilateral paresthesia
s, paresis
, decreased consciousness and/or loss of consciousness) followed by throbbing headache. Auditory symptoms are rare. However, a study showed a fluctuating low-tone sensorineural hearing loss
in more than 50% of patients with BAM with a noticeable change in hearing just before the onset of a migraine headache. The attacks of vertigo are usually concurrent with the headache and the family history is usually positive. The diagnostician must rule out: TIAs
, and paroxysmal vestibular disorder accompanied by headache.
There is also a familial vestibulopathy, familial benign recurrent vertigo (fBRV), where episodes of vertigo occur with or without migraine headache. Testing may show profound vestibular loss. The syndrome responds to acetazolamide
. Familial hemiplegic migraine
(FHM) has been linked to mutations in the calcium channel
gene. (Ophoff et al. 1966 cf. Lempert et al.)
A diagnosis of definite migraine-associated vertigo includes a case history of:
A diagnosis of probable migraine-associated vertigo includes a case history of episodic vestibular symptoms of at least moderate severity and one of the following:
Note that, in both of the above criteria, headache is not required to make the diagnosis of migraine-associated vertigo.
They add that, in patients with a clear-cut history, no vestibular tests are required. Other historical criteria which are helpful in making the diagnosis of migraine-associated vertigo are vertiginous symptoms throughout the patient’s entire life, a long history of motion intolerance, sensitivity to environmental stimuli, illusions of motion of the environment, and vertigo that awakens the patient.
MAV may occur at any age with a female:male ratio of between 1.5 and 5:1. Familial occurrence is not uncommon. In most patients, migraine headaches begin earlier in life than MAV with years of headache-free periods before MAV manifests.
In a diary study, the 1-month prevalence of MAV was 16%, frequency of MAV was higher and duration longer on days with headache, and MAV was a risk factor for co-morbid anxiety.
Vertigo (medical)
Vertigo is a type of dizziness, where there is a feeling of motion when one is stationary. The symptoms are due to a dysfunction of the vestibular system in the inner ear...
associated with a migraine
Migraine
Migraine is a chronic neurological disorder characterized by moderate to severe headaches, and nausea...
, either as a symptom of migraine or as a related but neurological disorder
Neurological disorder
A neurological disorder is a disorder of the body's nervous system. Structural, biochemical or electrical abnormalities in the brain, spinal cord, or in the nerves leading to or from them, can result in symptoms such as paralysis, muscle weakness, poor coordination, loss of sensation, seizures,...
; when referred to as a disease
Disease
A disease is an abnormal condition affecting the body of an organism. It is often construed to be a medical condition associated with specific symptoms and signs. It may be caused by external factors, such as infectious disease, or it may be caused by internal dysfunctions, such as autoimmune...
unto itself, it is also termed vestibular migraine, migrainous vertigo, or migraine-related vestibulopathy.
A 2010 report from the University of British Columbia
University of British Columbia
The University of British Columbia is a public research university. UBC’s two main campuses are situated in Vancouver and in Kelowna in the Okanagan Valley...
published in the journal Headache
Headache (journal)
Headache is a medical journal....
said that it "... is emerging as a popular diagnosis for patients with recurrent vertigo. Even though some authors believe that 'migraine associated vertigo,' is neither clinically nor biologically plausible as a migraine variant." Epidemiological studies leave no doubt that there is a strong link between vertigo and migraine.
Classification
Benign paroxysmal positional vertigoBenign paroxysmal positional vertigo
Benign paroxysmal positional vertigo is a disorder caused by problems in the inner ear. Its symptoms are repeated episodes of positional vertigo, that is, of a spinning sensation caused by changes in the position of the head.-Classification:...
- Migraine is commonly associated with BPPV, the most common vestibular disorder in patients presenting
Presenting
In medicine, the term presenting means not only present, but seen. For example, at birth most babies present head first and their presenting part is their head....
with dizziness. The two may be linked by genetic factors or by vascular damage to the labyrinth.
Ménière’s disease - There is an increased prevalence of migraine in patients with Ménière’s disease and migraine leads to a greater susceptibility of developing Ménière’s disease. But they can be distinguished. Migraine-associated vertigo may go on for days or even years, while Ménière’s disease never goes on longer than 24 hours.
Motion sickness is more prevalent in patients with migraine.
Psychiatric syndromes Dizziness and spinning vertigo are the second most common symptom of panic attack
Panic attack
Panic attacks are periods of intense fear or apprehension that are of sudden onset and of relatively brief duration. Panic attacks usually begin abruptly, reach a peak within 10 minutes, and subside over the next several hours...
s, and they can also present as a symptom of major depression. Migraine is a risk factor for developing major depression and panic disorder and vice versa.
Signs and symptoms
Vertigo is a medically recognized term for the symptom of vestibular systemVestibular system
The vestibular system, which contributes to balance in most mammals and to the sense of spatial orientation, is the sensory system that provides the leading contribution about movement and sense of balance. Together with the cochlea, a part of the auditory system, it constitutes the labyrinth of...
disturbance. It may include a feeling of rotation or illusory sensations of motion or both. The general term dizziness is used by nonmedical people for those symptoms but often refers to a feeling of light-headedness, giddiness, drowsiness, or faintness, all of which must be differentiated from true vertigo, since the latter symptoms might have other causes.
Motion sickness occurs more frequently in migraine patients (30-50%) than in controls. Benign paroxysmal vertigo of childhood is an example of migraine-associated vertigo in which headache does not often occur. Basilar migraine consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia
Ataxia
Ataxia is a neurological sign and symptom that consists of gross lack of coordination of muscle movements. Ataxia is a non-specific clinical manifestation implying dysfunction of the parts of the nervous system that coordinate movement, such as the cerebellum...
, dysarthria
Dysarthria
Dysarthria is a motor speech disorder resulting from neurological injury of the motor component of the motor-speech system and is characterized by poor articulation of phonemes...
, visual symptoms in both hemifields or both eyes, diplopia
Diplopia
Diplopia, commonly known as double vision, is the simultaneous perception of two images of a single object that may be displaced horizontally, vertically, or diagonally in relation to each other...
, bilateral paresthesia
Paresthesia
Paresthesia , spelled "paraesthesia" in British English, is a sensation of tingling, burning, pricking, or numbness of a person's skin with no apparent long-term physical effect. It is more generally known as the feeling of "pins and needles" or of a limb "falling asleep"...
s, paresis
Paresis
Paresis is a condition typified by partial loss of voluntary movement or by impaired movement. When used without qualifiers, it usually refers to the limbs, but it also can be used to describe the muscles of the eyes , the stomach , and also the vocal cords...
, decreased consciousness and/or loss of consciousness) followed by throbbing headache. Auditory symptoms are rare. However, a study showed a fluctuating low-tone sensorineural hearing loss
Sensorineural hearing loss
Sensorineural hearing loss is a type of hearing loss in which the root cause lies in the vestibulocochlear nerve , the inner ear, or central processing centers of the brain....
in more than 50% of patients with BAM with a noticeable change in hearing just before the onset of a migraine headache. The attacks of vertigo are usually concurrent with the headache and the family history is usually positive. The diagnostician must rule out: TIAs
Transient ischemic attack
A transient ischemic attack is a transient episode of neurologic dysfunction caused by ischemia – either focal brain, spinal cord or retinal – without acute infarction...
, and paroxysmal vestibular disorder accompanied by headache.
There is also a familial vestibulopathy, familial benign recurrent vertigo (fBRV), where episodes of vertigo occur with or without migraine headache. Testing may show profound vestibular loss. The syndrome responds to acetazolamide
Acetazolamide
Acetazolamide, sold under the trade name Diamox, is a carbonic anhydrase inhibitor that is used to treat glaucoma, epileptic seizures, Idiopathic intracranial hypertension , altitude sickness, cystinuria, and dural ectasia...
. Familial hemiplegic migraine
Familial hemiplegic migraine
Familial hemiplegic migraine is an autosomal dominant classical migraine subtype that typically includes hemiparesis during the aura phase. It can be accompanied by other symptoms, such as ataxia, coma and epileptic seizures...
(FHM) has been linked to mutations in the calcium channel
Calcium channel
A Calcium channel is an ion channel which displays selective permeability to calcium ions. It is sometimes synonymous as voltage-dependent calcium channel, although there are also ligand-gated calcium channels.-Comparison tables:...
gene. (Ophoff et al. 1966 cf. Lempert et al.)
Pathophysiology
The pathophysiology of MAV is not completely understood; both central and peripheral defects have been observed.Diagnosis
MAV is not recognized a distinct diagnostic entity. Lembert and Neuhauser propose criteria for definite and probable migraine-associated vertigo.A diagnosis of definite migraine-associated vertigo includes a case history of:
- episodic vestibular symptoms of at least moderate severity;
- current or previous history of migraine according to the 2004 International Classification of Headache DisordersInternational Classification of Headache DisordersThe International Classification of Headache Disorders is a detailed hierarchical classification of all headache-related disorders published by the International Headache Society...
; - one of the following migrainous symptoms during two or more attacks of vertigo: migrainous headache, photophobiaPhotophobiaPhotophobia is a symptom of abnormal intolerance to visual perception of light. As a medical symptom photophobia is not a morbid fear or phobia, but an experience of discomfort or pain to the eyes due to light exposure or by presence of actual physical photosensitivity of the eyes, though the term...
, phonophobia, visual or other aurasAura (symptom)An aura is a perceptual disturbance experienced by some migraine sufferers before a migraine headache, and the telltale sensation experienced by some people with epilepsy before a seizure. It often manifests as the perception of a strange light, an unpleasant smell or confusing thoughts or...
; and - other causes ruled out by appropriate investigations.
A diagnosis of probable migraine-associated vertigo includes a case history of episodic vestibular symptoms of at least moderate severity and one of the following:
- current or previous history of migraine according to the 2004 International Classification of Headache Disorders;
- migrainous symptoms during vestibular symptoms;
- migraine precipitants of vertigo in more than 50% of attacks, such as food triggers, sleep irregularities, or hormonal change;
- response to migraine medications in more than 50% of attacks; and
- other causes ruled out by appropriate investigations.
Note that, in both of the above criteria, headache is not required to make the diagnosis of migraine-associated vertigo.
They add that, in patients with a clear-cut history, no vestibular tests are required. Other historical criteria which are helpful in making the diagnosis of migraine-associated vertigo are vertiginous symptoms throughout the patient’s entire life, a long history of motion intolerance, sensitivity to environmental stimuli, illusions of motion of the environment, and vertigo that awakens the patient.
Treatment
Treatment of migraine-associated vertigo is the same as the treatment for migraine in general.Epidemiology
The prevalence of migraine and vertigo is 1.6 times higher in 200 dizziness clinic patients than in 200 age- and sex-matched controls from an orthopaedic clinic. Among the patients with unclassified or idiopathic vertigo, the prevalence of migraine was shown to be elevated. In another study, migraine patients reported 2.5 times more vertigo and also 2.5 more dizzy spells during headache-free periods than the controls.MAV may occur at any age with a female:male ratio of between 1.5 and 5:1. Familial occurrence is not uncommon. In most patients, migraine headaches begin earlier in life than MAV with years of headache-free periods before MAV manifests.
In a diary study, the 1-month prevalence of MAV was 16%, frequency of MAV was higher and duration longer on days with headache, and MAV was a risk factor for co-morbid anxiety.