From the Department of Neurootology, National Hospital of Neurology and Neurosurgery, London (Dr. Tsang, Miss Anwer) and the Ear Institute, University College London, and Guy’s and St Thomas’ NHS Foundation Trust, London, UK (Dr. Murdin).
Abstract
Objective: To review the clinical manifestations, diagnosis, and management of vestibular migraine (VM).
Methods: Review of the literature.
Results: Apart from headache, other symptoms of VM include unsteadiness, imbalance, and spontaneous as well as visual vertigo. Acute vestibular symptoms that qualify for VM must be of at least moderate or severe intensity which lasts within a time window of 5 minutes to 72 hours. The interindividual temporal association of headache and vertigo is highly variable in VM patients Grossly normal peripheral vestibular function and audiometry both during and between attacks distinguishes VM from its mimics. Treatment options for VM are mainly based on expert opinion and include lifestyle modifications, acute and prophylactic migraine pharmacotherapy, and vestibular rehabilitation therapy.
Conclusion: Despite a lack of diagnostic biomarkers for VM, a meticulous workup is important to exclude alternative mimics. More longitudinal and treatment studies are required to help elucidate the prognosis and optimal management of this condition.
The coexistence of migraine and vestibular symptoms has been mentioned in the headache literature for many years [1–3]. It was first addressed by Kayan and Hood in 1984, who found that dizziness and vertigo occurred in 54% of migraine patients compared with 30% of patients with tension-type headache [1]. The frequent coexistence of migraine and vertigo led researchers to hypothesize that their co-occurence could be due to more than mere chance. As per Lempert and Neuhauser’s evaluation, there is a lifetime prevalence of 16% for migraine and 7% for vertigo, with a 1.1 % chance of vertigo and migraine occurring together by chance alone [4]. In a study looking at the point prevalence of vertigo or dizziness among those presenting for a routine appointment at a headache center, an astounding 72.8% of those with severe headaches had vestibular symptoms [5].
Most epidemiologic studies of what we call vestibular migraine (VM) were based on presentations to specialist clinics and were performed in an era during which no established diagnostic criteria existed. Despite this, most neurootologists would consider VM to be one of the most common causes of spontaneous recurrent vertigo [6]. Neuhauser et al reported that VM was diagnosed in 7% of a group of 200 specialist clinic patients with dizziness and 9% of a group of 200 clinic patients who had migraine [2]. In a population-based study in Germany, the lifetime prevalence of VM according to the Neuhauser criteria was estimated to be 0.98% and the 12-month prevalence 0.89% [7]. The condition has a 3:1 female predilection [8].
VM has only recently been recognised as a separate migraine entity by the International Headache Society (IHS), appearing in the appendix of their International Classification of Headache Disorders (ICHD)–3 beta. The previous ICHD recognised vertigo as a migrainous symptom only within the framework of basilar migraine. The nomenclature used in the literature to describe this entity has been inconsistent and therefore confusing, including terms such as migraine-associated vertigo [9], migraine-related dizziness [3] or vertigo [10],migrainous vertigo [2], benign recurrent vertigo [11], and migraine-related vestibulopathy [12]. For the most part, these terms refer to the co-experience of migraine and vertigo or dizziness, with only a few terms having a more specific meaning of how the 2 symptoms relate temporally. Neuhauser and colleagues developed criteria in 2001 to classify migraineurs for whom vestibular symptoms are an integral part of migraine symptomatology, using the term migrainous vertigo [2]. Others preferred the terms migraine-associated dizziness or migraine-related dizziness [3] over migrainous vertigo because they felt the symptoms of vestibular dysfunction related to migraine are varied and may include gait instability and spatial disorientation but not necessarily with vertigo. To best avoid confounding nonvestibular dizziness or motion sickness associated with migraine, VM has been the preferred term because it emphasises the particular vestibular manifestation of migraine.
