Authored by Ravi Nayar
Vestibular migraine has been classified as a
specific entity in which vestibular symptomatology presents as part of a
migrainous disorder. New
and appropriate diagnostic criteria have been proposed by the Barany and
International Headache Societies [1]. The diagnosis of vestibular
migraine
isdetermined on the basis of the patient history and the exclusion of
other causes of vertigo [2]. We present a case of vestibular migraine,
which
no definitive clinical findings [3] and a few nonspecific VNG
abnormalities [4]. After exclusion of other conditions and by applying
the diagnostic
criteria, a diagnosis of Vestibular migraine was made. The patient is
being treated conservatively.
Case summary: A 31-year-old woman complained of a few episodes
of dizziness and persistent imbalance over the last 2 weeks. She had a
long-standing history of episodes of headaches during which she reported
intolerance to bright lights and loud sounds. The headaches as well
as dizziness were related to periods of stress and mental exertion. She
underwent pure tone audiometry, videonystagmography and MRI of
the brain which were all within normal limits. A provisional diagnosis
of vestibular migraine was arrived based on the history and by ruling
out other causes of vertigo. Interventions: She was advised lifestyle
modifications in terms of work life balance creation and measures to
managestress [5].
Outcome: The patient is asymptomatic to date. She is receiving
prophylactic medication for migraine. Regular visits to the therapist
are helping
in her overall approach to stressfull events in her life.
Conclusion: Vestibular migraine can be diagnosed by a process of exclusion of other conditions after detailed history, evaluation and
investigations. Conservative treatment is often adequate.
Keywords:Vestibular migraine; VNG; Lifestyle alterations; diagnostic dilemma; Case report
Migraine is one of the common forms of primary headache. Each
patient with migraine on this planet is a variant. The term Vestibular
Migraine (VM) is used for patients with a past or current history of
migraine, presenting with dizziness as the predominant symptom
with or without headache. Prosper Meniere, the French physician
who first described the vertiginous syndrome that now goes after
his name, was a victim of severe migraine himself .The relationship
between these two illnesses was suspected, and written about for
many years, under various names such as Migraine -Anxiety Related
Dizziness (MARD), Migraine-induced Vertigo or Migrainous Vertigo.
But it was only in the year 2001 that the International Headache
Society and Barany Society reached a consensus on the diagnostic
criteria of Vestibular Migraine. Diagnosing vestibular migraine is
a challenging task, as Migraine can be present in association with
Meniere’s disease [6], BPPV, Epilepsy and often Audio-vestibular
investigations and imaging are needed to exclude other peripheral
and central vestibular disorders [7].
Case presentation
History: A 31-year-old woman presented with complaints of
persistent postural imbalance for two weeks. Superimposed on
this, the patient had two short episodes of sensation of dizziness
(non-rotatory) which lasted for less than two minutes. These two
episodes were not related to change in head position or change
in posture. There was an associated mild nausea. There were no
aural symptoms. There was no difficulty in walking, speech visual
disturbance or any indication of a neurological affliction. She was not
on any medications. She had complained of positional vertigo 3
to 4 years ago. This occurred while lying down in bed and turning to
either side. The duration of each episode was a few minutes, without
related nausea or vomiting. These symptoms spontaneously
resolved in 2 weeks. In the past she had migrainous headaches
since her school days. The headaches were unilateral, throbbing in
nature. She couldn’t tolerate bright light and loud sounds during the
headaches. However, the dizziness was not related temporally to the
headaches, though the headaches as well as dizziness were related
to periods of stress and mental exertion. Clinical examination
and Neuro-otology tests: The ears were normal. Romberg’s test
and Unterberger’s stepping test were normal. There was no gait
abnormality. Pure tone audiometry revealed normal hearing in
both ears. Videonystagmography findings (using the Balance Eye
VNG (R)) were as follows
1. A saccadic vertical smooth pursuit.
2. A low amplitude up-beating nystagmus on removal of
fixation.
3. A left beating horizontal nystagmus on gaze testing
without fixation (Figure 1).
An MRI of the brain was requested (in view of saccadic vertical
smooth pursuit and up-beating nystagmus), which was reported as
normal. A provisional diagnosis of vestibular migraine was made.
Acute treatment of the vertigo was not required, as the patient’s
symptoms were mild at the time of presentation. She was advised
lifestyle modifications including avoidance of stress [8] For
Migraine prophylaxis she was advised Tab Flunarizine [9] which
was started in a dose of 5 mg per day which was discontinued after
a month and she was advised a close follow up. She is asymptomatic
for the past 6 months.
Vestibular Migraine (VM) is the recommended term for
this condition. The previous terms used were migrainous
vertigo, migraine-associated vertigo, migraine-associated
dizzinessmigraine-related vestibulopathy [10], Despite the notes on
association between episodic vertigo and migraine as early as 1873,
VM remained a poorly defined entity [11]. In 1979, Dr Robert Slater,
a Neurologist described features of a vertiginous syndrome without
auditory symptoms and named it as “benign recurrent vertigo”. The
spectrum of VM however is still evolving and more clarity is being
obtained through investigation and research. Migraine and vertigo
are common neurologic complaints in the general population, each
being more common in the presence of the other. The link therefore
was initially suspected on the basis of epidemiology. Migraine
classically is a headache with or without aura though migraine
related conditions can be diagnosed without headache. The aura
may be abnormal smells, lights or hallucinations. Vertigo is not an
aura like symptom, as its duration is too long and may arise during
or after the headache. Other auras may co-exist with vertigo.
Vestibular symptoms commonly seen are spontaneous vertigo,
vertigo induced by position, vertigo on exposure to complex visual
stimulus, vertigo on head motion, imbalance, dizziness and extreme
sensitivity to motion. Typically, VM is spontaneous and positional or
spontaneous transforming into positional.VM can affect children as
well adults. Females appear to be more affected than males. Various
potential mechanisms of pathogenesis have been proposed like
stimulation of trigemino- vestibular connections, migraine induced
ischemia of inner ear, ion-channel defect, and endolymphatic
hydrops in migraine [12,13]. Our patient is a 31-year-oldwoman with
a history of long-standing migraine who presented with symptoms
of dizziness and imbalance. The features of vertigo which lead us
to suspect vestibular migraine include the nature and duration of
the first episode of positional vertigo as well as the presence of preexisting
migraine since childhood. Positional vertigo is described to
occur in vestibular migraine, as either spontaneous or positional or
both. It differs from Benign Paroxysmal Positional Vertigo in that
the duration of the vertigo episode is longer, lasting often as long
as the head position is maintained in the dependant position, the
condition often self-limits earlier even without treatment [14].The
patient’s episode of positional vertigo fits with this description,
hence our initial suspicion. In addition, she complained of nausea,
which along with other vegetative symptoms are often described
in VM.
There are no conclusive diagnostic tests. In the acute phase
there is minimal or no spontaneous nystagmus [15]. Vestibular
testing by VNG usually reveals non-specific abnormalities, however
the presence of up beating nystagmus as noted in our patient, has
been described as a differentiating feature from other vestibular
syndromes. However, as this can also suggest a central lesion, she
was advised MRI imaging. The other common differentials of VM
are Meniere’s disease, BPPV, persistent postural phobic dizziness,
brainstem ischemia, migraine with brainstem aura (Formerly
Basilar migraine) and vestibular paroxysmia.
The patient did not complain of tinnitus and the audiometry
findings were normal enabling us to rule out Menieres disease.
The other conditions could be ruled out with a judicious review
of history, findings and investigations. The treatment of acute
attacks is reserved for episodes lasting longer than 20-30 minutes.
This is done using vestibular suppressants such as Meclizine,
Dimenhydrinate, Droperidol, Promethazine, Prochlorperazine
[16-20]. It is to be noted that the drugs used for acute attacks of
vestibular migraine are different from those used to treat acute
headaches of migraine. In our case, however we adopted a more
conservative approach, as the symptoms had subsided.
Preventive treatment for migraine includes avoidance of
triggers and use of drugs for prophylaxis in line with those used to
treat classical migraine as suggested by the American Association of
Neurology (AAN) namely beta-blockers, tricyclic anti-depressants,
calcium channel blockers and some anti-epileptic drugs [21].
Treatment of the co-morbid conditions like anxiety includes
physical exercise, lifestyle changes, stress management, diet, which
need careful evaluation and long term follow up [22].In our patient,
we suggested lifestyle changes to reduce stress and change attitudes
to stressful circumstances and used the help of a therapist to ensure
continuance of treatment and prevent recurrence of symptoms,
with sparing use of prophylactic medications for headache as
advised by the neurologists [23].
Vestibular migraine is a difficult diagnosis to make and it
requires a high index of suspicion and careful methodical ruling
out of other conditions. Awareness of this cause of vertigo is the
first step in establishing the diagnosis hence our desire to present
this case. The need for neurotologic investigation, and imaging to
rule out other differentials and the ability to treat this condition
conservatively are highlighted.
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