Vestibular Migraine, Migraine Vertigo, Migraine Associated Dizziness
Migraine associated dizziness, vestibular migraine, vestibular Méniére's Disease, episodic floating, and a variety of similar characterizations can be quite difficult to sort out. These are generally lumped together in a group known as migraine associated vertigo. A careful history usually provides the necessary diagnostic clues.
See the website of TC Hain for a more detailed discussion. This particular website is a source for much common information, including much of what is written below. Migraine is common in most societies, more common in women, generally affecting almost a third of women of child bearing age. Migraine is more common than Méniére's Disease but the experience at the Tampa Bay Hearing and Balance Center is that migraine associated vertigo has a prevalence rate in our patients about the same or slightly less common than Méniére's Disease. In other words, while dizziness of various sorts is common in migraine, having such symptoms quite independent of migraine headache is much less common. For comparison, then while 5-10% of the population, more in fertile women, has migraine and less than 0.5% of the population has Ménière's, the prevalence of migraine associated vertigo largely independent of headache seems just a bit less common than Méniére's Disease.
Both migraine associated dizziness and Ménière's are part of a veritable cornucopia of dizzy disorders, more than one of which may any given patient. For example, it appears that a variety of dizziness related diagnoses may be more common in migraine patients and that persons who have dizziness of various sorts are more likely to have a migraine history. The challenge, then, is to sort out what may be migraine from other problems. For example, motion intolerance is quite common in migraine, affecting about half of migraineurs. Motion intolerance independent of migraine is common in childhood and is common after a variety of balance system insults.
The migraine with which the lay public is familiar involves headache and sometimes involves having a warning called an "aura". The aura can be many things. Most commonly, it is a transient visual disturbance such as zigzag lights, halos, bright spots, and associated dimness of vision which may last 5-30 minutes. Most of these auras resolve without associated symptoms, but some are followed by headache. Other migraine associated symptoms may precede headache or start with the headache.
A patient may have migraine of more than one sort as life progresses. For example, Migraine without aura and migraine with aura are quite common from menarche until near menopause, generally until about age 40-45. Migraine with vertigo tends to be more common without headache after age 45 but of course may occur earlier, too. Migraine headaches may occur without nausea and migraine-related vertigo with nausea may occur without headache. When in a period of recurring migrainous vertigo or when more affected by migraine associated dizziness, motion intolerance can be more troublesome, too. For persons with migraine related dizziness, migrainous headache as a past history is highly typical but not required. So called sinus headaches are thought to be mostly migraine and may be the only prior form of migraine in some patients who have migraine related dizziness. Auditory symptoms are common in association with migraine related dizziness but distinguish themselves as usually bilateral while in Méniére's Disease ear specific symptoms are typically in just one ear at a time (can affect both ears over time, though, in a non-simultaneous fashion). Hyperacusis or excessive noise sensitivity is common in migraine, which may differentiate it from most ear disorders. Sensitivity to light (photophobia), especially during a migraine related event, is also commonly present.
If one has the opportunity to observe a vertigo patient during an event, migraineurs seldom have spontaneous nystagmus or may have very little nystagmus. In contrast, acute viral vertigo syndrome, Méniére's Disease patients, and benign paroxysmal positioning vertigo patients commonly have rather easily observable nystagmus. If the migraineur has nystagmus, it is usually vertical. In Ménière's, it is typically horizontal and in BPPV, it is more likely to be rotary but can on relatively rare occasion be horizontal. In acute viral vertigo syndrome, nystagmus is more typically slightly rotary but can be horizontal. Acute onset vertically directed nystagmus which persists, especially with ataxia, generally implies other brainstem disorders.
Duration of a vertigo event may not differentiate migraine from Méniére's Disease very well. Both commonly last hours. Minor events of both can be relatively short lived. In both, position change during the event can exacerbate symptoms as is also true in acute viral vertigo syndrome. In migraine, spells of vertigo may occasionally last days as in acute viral vertigo syndrome or recurrent vestibular neuritis. What is somewhat differentiating is the timing of associated symptoms. In migraine associated vertigo, if ear specific symptoms occur, such as hearing loss or tinnitus, they tend to occur at the onset of the vertigo. In Méniére's Disease, the hearing commonly fluctuates downward with increased unilateral tinnitus and pressure in the affected ear hours to days before the onset of the vertigo. In later Ménière's, the hearing remains down even during periods when vertigo is not present, especially in the low frequencies. In far advanced Méniére's Disease, the hearing may no longer fluctuate but tinnitus commonly does and the character of the hearing loss makes the question between migraine and Méniére's Disease easier to differentiate. Severe unilateral tinnitus in attacks with nausea and minimal to mild dizziness may be a form of migraine, too.
While headache is not required to make the diagnosis of migraine associated dizziness, a form of migraine headache history is present in almost all of these patients and a high percentage of them have a family history of a migraine headache type. Consider that in migraine, the aura may occur without headache. It should then not seem strange that vertigo may occur without headache.
Two relatively common forms of migraine-associated vertigo seem to occur. Benign Paroxysmal Vertigo of childhood may be seen in children as young as age 2. These children commonly are quite frightened, grab a parent and hold on for minutes, and resolve, returning to play. Sometimes, it is associated with stomachache and nausea. Its occurrence portends a relatively high probability of developing more classic migraine later. A similar but usually longer duration form of paroxysmal vertigo lasting under an hour may affect adults, with or without ear specific symptoms and with or without headache. When these individuals do experience headache, they commonly do not have associated dizziness.
When migraine occurs in association with other brainstem-related dysfunction, the disorder is called Basilar Migraine. Those symptoms typically include vertigo, tinnitus, and decreased hearing, but careful questioning may also reveal a clumsy gait, slurred speech and a variety of visual complaints. Odd sensations in other parts of the body may occur simultaneously, too. Severe throbbing headache is common as these symptoms wane or become of lesser focus. This form of migraine is not usually long lasting but is often highly disruptive.
Odd patterns of mild hearing loss are common in migraineurs but not typically the patterns that go along with Méniére's Disease. Similarly, major specific vestibular loss is not typical of migraine but mild forms of vestibular dysfunction are not rare in vestibular testing. However, while auditory symptoms are not that common in migraine associated dizziness, they may be recurring in basilar artery migraine. The distinguishing feature of migraine from Ménière's is that the hearing loss of migraine occurs simultaneous with the vertigo whereas in Ménière's, it tends to occur hours to days ahead of the vertigo. Distinguishing basilar migraine, a much more rare disorder, requires other associated symptoms of brainstem and visual cortex dysfunction.
Treatment of Migraine associated dizziness is usually straightforward, but can be quite complex. When the episodes are quite infrequent and not terribly severe, no treatment may be necessary. A good patient education may suffice. In our experience, a period of migraine associated vertigo may last months to a few years, but is seldom a recurring problem for more than a year or two. For those with symptoms which recur in a disruptive pattern, we commonly find trigger issues which are manageable. For example, high stress which affects sleep patterns is common. For those patients, medications which promote sleep and improved stress management are often helpful. Antidepressants can be helpful, either the older sedating forms to help with sleep called tricylcics or tetracyclics or the new forms called SSRI agents. For children, if anything is required, and often nothing is, low dose sedating antihistamine such as cyproheptadine may be helpful. We have used a variety of agents including beta-blockers, calcium channel blockers, depakote, and topiramate. In contrast to TC Hain, our experience has been that low dose topiramate is well tolerated if started off as low dose sprinkles, building dose as symptoms recur, or "titrating" dose. Seldom do our patients build to a dose exceeding 50 mg per day. We also titrate the sedating antidepressants, again, seldom exceeding 20-30 mg of nortriptyline per night.
Many suggest dietary manipulation such as eliminating chocolate, hard cheeses, alcohol and monosodium glutamate but our experience is that these are of uncertain value. Of course, alcohol can itself be a headache trigger, but we do not see it is migrainous vertigo trigger.
In summary, when recurring vertigo has a defined onset and a duration of hours to days, especially without ear-specific symptoms, migraine is a common cause. To be more definitive, a careful history and investigations of hearing and balance function and imaging of the brain are required.