Vestibular Migraines

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Vestibular Migraines

Otology/Audiology
Author Credentials 

Isaac Erbele, MD
Fellow
Otology, Neurotology, and Skull Base
Hearing and Balance Center/Louisiana State University Health Sciences Center
Baton Rouge, LA

 

Module Summary

Vestibular migraine is a clinical diagnosis that can have variable presentation, with or without headache.  Care must be taken to consider it for any vestibular patient undergoing evaluation for surgical intervention.  Lifestyle changes such as stress reduction, diet modification, and improved sleep hygiene may help control some episodes.  Prophylactic and abortive medical therapies are available for vestibular migraine, but evidence is mixed with regards to their effects on vertigo.  The same is true of vestibular physical therapy.  Therapies involving monoclonal antibodies are promising, but more evidence is necessary for their routine use.

Module Learning Objectives 
  1. Distinguish between vestibular migraine and Meniere’s disease.
  2. Discuss areas of research in vestibular migraine.
  3. Employ an initial treatment strategy for suspected vestibular migraine.

 

Pathogenesis

Learning Objectives 
  1. Discuss how elevated potassium leads to the spreading wave of depression found in migraine.
  2. Theorize how potassium elevation might affect trigmeninal fibers associated with pial arteries.
  3. Discuss theories of central vasospasm and vasodilation as causes of migraine.
  4. Evaluate strength of available theories of pathogenesis.
  5. Identify EEG changes in migraine.

 

References 
  1. Baloh RW, Honrubia V, Kerber K. Migraine. In: Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System. 4 ed. New York: Oxford University Press USA; 2011. p. 287-301.
  2. Crane B, Eggers S, Zee D. Central Vestibular Disorders. In: Flint PW, Haughey BH, Lund VJ, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6 ed.: Elsevier/Saunders; 2014. p. 2567-2580.
  3. Harker L. Migraine. In: Jackler RK, Brackmann DE, eds. Neurotology. 2 ed. Philadelphia: Mosby; 2005. p. 510-517.

 

Incidence

Learning Objectives 
  1. Identify populations most at risk for migraine headaches.
  2. Identify population with highest risk of vestibular migraine.
  3. Compare populations of patients with migraine headaches with vestibular migraine.
  4. Compare incidence of vestibular migraine and Ménière’s in the general population.
  5. Identify incidence of vestibular migraine in patients with Ménière’s. 

 

References 
  1. Lempert T, Neuhauser H. Epidemiology of vertigo, migraine and vestibular migraine. J Neurol. 2009;256(3):333-338.
  2. Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016;263 Suppl 1:S82-89.
  3. Formeister EJ, Rizk HG, Kohn MA, Sharon JD. The Epidemiology of Vestibular Migraine: A Population-based Survey Study. Otol Neurotol. 2018;39(8):1037-1044.
  4. Schulz KA, Esmati E, Godley FA, Hill CL, Monfared A, Teixido M, et al. Patterns of Migraine Disease in Otolaryngology: A CHEER Network Study. Otolaryngology–Head and Neck Surgery. 2018;159(1):42-50.
  5. Lipton RB, Stewart WF, Diamond S, Diamond ML, Reed M. Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache. 2001;41(7):646-657.

 

Genetics

Learning Objectives 
  1. Discuss familial patterns of migraine.
  2. Describe inheritance pattern of familial hemiplegic migraine.
  3. Identify genes associated with familial hemiplegic migraine.

 

References 
  1. Baloh RW, Honrubia V, Kerber K. Migraine. In: Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System. 4 ed. New York: Oxford University Press USA; 2011:287-301.
  2. Lempert T, von Brevern M. Vestibular Migraine. Neurol Clin. 2019;37(4):695-706.

 

Patient Evaluation

Learning Objectives 
  1. Describe symptoms of vestibular migraine:
  • Vestibular symptoms
  • Length and frequency of vestibular symptoms
  • Presence or absence of headache
  • Auditory symptoms
  1. Compare current and historic definition for “definite” and “probable” vestibular migraine (Neuhauser 2001 and Lempert 2012).
  2. Compare and contrast patient history criteria meeting IHS definition for vestibular migraine versus the Barany Society’s 2015 criteria (Lopez-Escamez 2015) for Ménière’s disease.
  3. List historic terms for vestibular migraine and migraine with brainstem aura.
  4. Compare criteria for migraine with brainstem aura and hemiplegic migraine.
  5. Describe migraine equivalents:
  • Benign paroxysmal vertigo of childhood
  • Benign recurrent vertigo of adulthood
  1. Compare migraine with brainstem aura (previously basilar migraine) with vestibular migraine. 
  2. Apply knowledge of migraine and Ménière’s disease to assess “Vestibular Ménière’s” and “Cochlear Ménière’s.”
  3. Describe relationship between Benign Paroxysmal Vertigo and vestibular migraine.
  4. Recognize symptoms of cerebellar stroke.
  5. Discuss strengths and limitations of using the Dizziness Handicap Index (DHI) to evaluate patient’s symptomatic dizziness and progress in treatment.

 

References 
  1. Crane B, Eggers S, Zee D. Central Vestibular Disorders. In: Flint PW, Haughey BH, Lund VJ, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6 ed.: Elsevier/Saunders; 2014:2567-2580.
  2. Baloh RW, Honrubia V, Kerber K. Migraine. In: Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System. 4 ed. New York: Oxford University Press USA; 2011:287-301.
  3. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology. 2001;56(4):436-441.
  4. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-172.
  5. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  6. Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandala M, et al. Diagnostic criteria for Meniere's disease. J Vestib Res. 2015;25(1):1-7.
  7. Jacobson GP, Newman CW. The development of the Dizziness Handicap Inventory. Arch Otolaryngol Head Neck Surg. 1990;116(4):424-427.

 

Measurement of Functional Status

Learning Objectives 
  • Review vestibular testing findings common in vestibular migraine:
    • Rotational chair
    • Calorics
    • Video head impulse test (VHIT)
  • Describe controversy and limitations of Vestibular Evoked Myogenic Potential (VEMP) testing.

 

References 
  1. Arriaga MA, Chen DA, Hillman TA, Kunschner L, Arriaga RY. Visually enhanced vestibulo-ocular reflex: a diagnostic tool for migraine vestibulopathy. Laryngoscope. 2006;116(9):1577-1579.
  2. Lempert T, von Brevern M. Vestibular Migraine. Neurol Clin. 2019;37(4):695-706.
  3. Zuniga MG, Janky KL, Schubert MC, Carey JP. Can Vestibular-Evoked Myogenic Potentials Help Differentiate Ménière Disease from Vestibular Migraine? Otolaryngology–Head and Neck Surgery. 2012;146(5):788-796.

 

Imaging

Learning Objectives 
  1. Discuss role of CT without contrast in suspected acute cerebrovascular event.
  2. Describe association between MRI white matter changes and vestibular migraine.

 

References 
  1. Mankekar G, Jeha G, Erbele I, Klumpp M, Sevy A, Mehta R, et al. Do central vestibular findings predict abnormal findings on magnetic resonance imaging? J Laryngol Otol. 2019:1-6.
  2. Crane B, Eggers S, Zee D. Central Vestibular Disorders. In: Flint PW, Haughey BH, Lund VJ, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6 ed.: Elsevier/Saunders; 2014:2567-2580.

 

Treatment

Learning Objectives 
  1. Discuss common triggers for migraine, and role of avoidance:
  • Diet
  • Sleep
  • Stress
  • Hormone changes

 

References 
  1. Crane B, Eggers S, Zee D. Central Vestibular Disorders. In: Flint PW, Haughey BH, Lund VJ, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6 ed.: Elsevier/Saunders; 2014:2567-2580.
  2. Baloh RW, Honrubia V, Kerber K. Migraine. In: Baloh and Honrubia's Clinical Neurophysiology of the Vestibular System. 4 ed. New York: Oxford University Press USA; 2011:287-301.

 

Medical Therapies

Learning Objectives 
  1. Review common medical therapies and limitations.
  2. Categorize common migraine medications into prophylactic or abortive.
  3. Compare goals of abortive and prophylactic medical therapy.
  4. Evaluate strength of evidence to support prophylactic and abortive therapies.
  5. Discuss status of monoclonal antibody prophylactic therapy.

 

References 
  1. Crane B, Eggers S, Zee D. Central Vestibular Disorders. In: Flint PW, Haughey BH, Lund VJ, et al., eds. Cummings Otolaryngology: Head and Neck Surgery. 6 ed.: Elsevier/Saunders; 2014. p. 2567-2580.
  2. Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016;263 Suppl 1:S82-89.
  3. Lempert T, von Brevern M. Vestibular Migraine. Neurol Clin. 2019;37(4):695-706.
  4. Ceriani CEJ, Wilhour DA, Silberstein SD. Novel Medications for the Treatment of Migraine. Headache. 2019.

 

Surgical Therapies

Learning Objectives 
  1. Recognize pitfalls related to diagnostic uncertainty between vestibular migraine and other surgical vestibular conditions:
  • Ménière’s disease and endolymphatic sac surgery or vestibular nerve section/labyrinthectomy
  • Superior semicircular canal dehiscence and its repair.

 

References 
  1. Weinreich H, Crane B, Carey JP, Minor LB. Superior Semicircular Canal Dehiscence Syndrome. In: Brackmann DE, Shelton C, Arriaga MA, eds. Otologic surgery. 4th ed. Philadelphia: Elsevier, Inc; 2016. p. 445-457.
  2. Buchman C, Adunka O. Translabyrinthine Vestibular Neurectomy. In: Brackmann DE, Shelton C, Arriaga MA, eds. Otologic surgery. 4th ed. Philadelphia: Elsevier, Inc; 2016. p. 397-407.
  3. Packer M, Welling D. Surgery of the Endolymphatic Sac. In: Brackmann DE, Shelton C, Arriaga MA, eds. Otologic surgery. 4th ed. Philadelphia: Elsevier, Inc; 2016. p. 362-376.

 

Rehabilitation

Learning Objectives 
  1. Discuss role of vestibular physical therapy in improving vestibular migraine.
  2. Discuss limitations of evidence supporting vestibular physical therapy.

 

References 
  1. Alghadir AH, Anwer S. Effects of Vestibular Rehabilitation in the Management of a Vestibular Migraine: A Review. Front Neurol. 2018;9:440.
  2. Dunlap PM, Holmberg JM, Whitney SL. Vestibular rehabilitation: advances in peripheral and central vestibular disorders. Curr Opin Neurol. 2019;32(1):137-144.

 

Case Studies

  1. A 43-year-old woman presents with “rocking” dizziness, lasting 3 hours and occurring 2-3 times a week.  They occur with severe headaches on one side of the head, visual aura, photophobia, and phonophobia.  They started around menarche but have been occurring with greater frequency over the last year.  She has a family history of migraine.  She has elevated visually-enhanced vestibular ocular reflexes and non-specific white matter changes on MRI.
  • Meets criteria for definite vestibular migraine
  1. A 25-year-old male presents with left low frequency fluctuating hearing loss, which occurs with vertigo and visual aura.  This has occurred 6 times over the last year.  Episodes last about 10 minutes.  He has no family history of migraine.  No abnormalities on imaging or vestibular testing.
  • Meets criteria for BOTH probable vestibular migraine AND definite Meniere’s disease

 

References 
  1. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition (beta version). Cephalalgia. 2013;33(9):629-808.
  2. Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-172.
  3. Lopez-Escamez JA, Carey J, Chung WH, Goebel JA, Magnusson M, Mandala M, et al. Diagnostic criteria for Meniere's disease. J Vestib Res. 2015;25(1):1-7.

 

Review

Review Questions 
  1. According the International Headache Society, what length of time can episodes of moderate to severe vestibular symptoms last to meet the criteria for vestibular migraine?

A. 0 to 30 seconds
B. 30 seconds to 5 minutes
C. 5 minutes to 72 hours
D. More than 72 hours

Answer: C

 

  1. How many episodes are necessary?

A. 1
B. 3
C. 5
D. 10

Answer: C

 

  1. Vestibular migraine can occur without headache? (True/False)

Answer: True

 

  1. When initiating prophylactic therapies for vestibular migraine, what is a reasonable goal for control?

A. Complete resolution of episodes
B. 90% reduction in episodes
C. 75% reduction in episodes
D. 50% reduction in episodes

Answer: D

 

Resources 

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  1. Annual Meeting Webcast (AMW):