Vestibular migraine

Updated 2020

What is vestibular migraine?

Dizziness and headache are common symptoms experienced by many patients daily.  In many patient’s dizziness and headache may coincide without being related.

However, the two symptoms may be linked and migraine which is a common cause of headache may also cause dizziness. In these patients the term migraine-associated vertigo (MAV) may be used. MAV is a term used in a broader sense for a group of conditions, of which vestibular migraine is one.

The term vestibular migraine is more commonly used. Vestibular migraine has been defined by the International Headache Society. They make use of specific criteria to establish the diagnosis of vestibular migraine. Oponents to this argue that the diagnosis is based on a “committee decision”, and that a committee of so-called experts should not necessarily have the final say in diagnosing a condition whithout any confirmatory test.

Vestibular migraine or MAV is one of the most common cause of dizziness, verigo and balance impairment.

Vestibular migraine

Visual sensitivity for bright lights and movement in vestibular migraine

How common is vestibular migraine and migraine-associated vertigo (MAV) in the general population?

In general, it is estimated that 14% of the adult female population and about 7% of the adult male population suffer from migraine. It is estimated that 1% of the population suffers from MAV. Compare this to Meniere’s disease (MD) which is far less common with a prevalence of more or less 0,05%. MD is therefore most likely over-diagnosed and MAV under-diagnosed.

Who suffers from vestibular migraine and migraine-associated vertigo (MAV) and why?

Migraine is likely a polygenetic condition but where many genes contribute a little risk. It is much more common in females and more so in middle aged individuals. Female hormonal fluctuation or therapy, lack of exercise, poor sleeping patterns and stress can all contribute to the development of MAV. It is commonly accepted that there are most often dietary triggers and it is worthwhile to try and eliminate them as far as possible. Migraine prevention diets and dietary advise is freely available on the internet.

The link between vestibular migraine, migraine associated vertigo (MAV) and Meniere’s disease.

There is a link between vestibular migraine, Meniere’s disease (MD) and motion sickness. Many patients with vestibular migraine are wrongly diagnosed with MD. Patients with MD is more likely to suffer from migraine and patients with migraine are more likely to suffer from benign paroxysmal positional vertigo (BPPV), Motion sickness and intollerance to motion is common in migraine sufferers.

How does vertigo occur in migraine?

 There are a few theories namely:

  • Irregular neurotransmitter (like seretonin) secretion in the brain
  • Vascular spasm causing impaired bloodflow to the inner ear and brainstem
  • Altered metabolism of the cerebellum
  • Increased senses and sensory exaggerations for movement

How do we define migraine associated vertigo (MAV)?

There is no blood test or scan available to confirm the diagnosis. MAV is therefore a clinical diagnosis. I find it very logical and practical to define it as simplistically done by Dr TC Hain, neurologist, based on his extensive experience in managing thousands of patients.

  • Headaches that reduce ability to carry out activities of daily living, either ongoing, or having a past history of migraine headaches (e.g. previous aura)
  • Dizziness
  • No other reasonable explanation (very importand to look)
  • Responds to a migraine medication

Other common symptoms of vestibular migraine and migraine associated vertigo (MAV).

 Symptoms can be episodic or chronic, lasting basically any time. The following symptoms are common in patients:

  • Photophobia (light sensitivity)
  • Phonophobia (sound sensitivity)
  • Tinnitus
  • Sensitivity to motion, medication, certain smells, weather and mild pain stimulation
  • Sometimes feeling better after a nap.
  • Preferring a dark quiet room and closing their eyes.
  • Hearing loss is uncommon

Headache is not required to make the diagnosis of migraine associated vertigo (MAV)!

Other migraine associated vertigo (MAV) syndromes

Migraine with and without aura are the most common forms of migraine and also the most common types that may present with vertigo. Benign recurrent vertigo of adults (BRV), basilar migraine, benign paroxysmal vertigo of childhood, cyclic vomiting and familial syndromes such as familial episodic ataxia are less common.

The management of vestibular migraine and migraine associated vertigo (MAV)

There is no diagnostic test available to confirm vestibular migraine and MAV. Nystagmus may be observed but the neur-otological examination is often normal. A magnetic resonance imaging (MRI) may be ordered to rule out other pathology.

Avoiding triggers and modifying lifestyle are advised. This include reducing stress, better sleep patterns and regular exersise. Also avoiding unneccessary motion, flying, strong odours, loud noises and bright or flickering lights may come in very handy.

Avoidance of dietery triggers are extremely important and a “migraine diet” should be part of any migraine management plan.

Medical treatment include supplements such as magnesium, prophylactic drugs to prevent attacks and to control chronic symptoms and drugs prescribed to treat acute symptoms (abortative drugs). In some cases combinations of drugs will have to be used. Botulinum toxin injection may also be of value

 It is advisable that especially children with migraine have their eyes tested

Further reading

Migraine-associated vertigo and dizziness as presenting complaint in a private general medical practice

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