Chapter 14-23: Vestibular Migraine

TEXTBOOK PRESENTATION

Classically, migraine sufferers complain of intermittent attacks of severe unilateral throbbing headache associated with photophobia, phonophobia, nausea and vomiting (see Chapter 20-14: Migraine Headaches). Headaches may be preceded by an aura that is usually visual (scotoma or scintillating lights). Occasionally, patients with migraine disorders have vertigo, an entity referred to as vestibular migraine. This discussion will focus on vestibular migraines. (See Chapter 20-14: Migraine Headaches for a more complete discussion of migraine.)

DISEASE HIGHLIGHTS

1. Dizziness or vertigo is common during a migraine attack, affecting as many as 24.5% of patients with migraine accompanied by aura and up to 47.5% of patients with severe migraine pain (≥ 7/10).

2. Characteristics of the vertigo in vestibular migraine include

   1. Lasts seconds to a week

   2. The vertigo is constant in 30% of patients and positional (brought on by head movement) in 60% of patients.

   3. The temporal association of vertigo with headache is variable.

      1. The vertigo may precede, be concurrent with, follow, or be temporally unrelated to headache.

      2. Vertigo was regularly associated with headache in 45% of patients and occurred with and without headache in 48% of patients. In 6% of patients, vertigo and migraine did not occur together.

      3. However, in 95% of patients, a history of migraines preceded the development of vertigo (by an average of 8–20 years).

A history of migraines almost always precedes the development of vestibular migraine. Patients with a new headache accompanied by vertigo should be evaluated for other diagnoses (eg, cerebellar hemorrhage, VAD).

EVIDENCE-BASED DIAGNOSIS

1. The International Headache Society criteria for definite vestibular migraine require all 4 of the following:

   1. ≥ 5 episodes of moderate to severe vertigo, lasting 5 minutes to 72 hours

   2. Current or prior history of migraine with or without aura

   3. > 50% of vertiginous attacks accompanied by ≥ 1 migrainous symptoms:

      1. Headache with ≥ 2 of the following: One-sided location, pulsatile, moderate to severe, aggravation with activity

      2. Photophobia or phonophobia

      3. Visual aura

   4. Not better accounted for by another vestibular diagnosis (This is particularly complex as Meniere attacks and other vestibular conditions can trigger migraine attacks.)

2. Attack characteristics

   1. Common symptoms include nausea (95%), photophobia (70%), headache (65%), phonophobia (10%), and aura (10%).

   2. Central, spontaneous, or positional nystagmus may be present during the attack.

   3. All patients with vestibular migraine have a normal finger to nose, heel to shin, and rapid alternating movements.

   4. 65% of patients have disturbances of gait, but only 5% were unable to stand and walk.

   5. 70% of patient have an abnormal Romberg sign.

   6. Pathologic cranial nerve or cerebellar findings signs are seen in < 10% of patients with vestibular migraine during an attack.

   7. Hearing loss, tinnitus, and aural pressure occur in up to 38% of patients with vestibular migraine but, unlike Meniere disease, are usually mild, do not progress, or cause severe hearing loss between attacks.

Clues that suggest an alterative diagnosis and the need for additional evaluation in ...