Ear Center: Migraine Related Vertigo
Migraine-Related Vertigo (MRV)
Although not widely accepted by classically trained neurologists, there appears to be a relationship between migraine disease, episodic vertigo, and vestibular dysfunction. In the literature, the diagnosis of episodic vertigo caused by migraine disease is referred to by various names including:
- migraine-related vertigo (MRV)
- migraine-associated dizziness
- atypical migraine variant with vertigo.
MRV may be confused with Meniere"s Disease unless a careful history is taken. To complicate matters further, some patients with Meniere"s Disease suffer from migraine disease. Short duration vertigo associated with a headache is suggestive of an "aura". Prolonged duration vertigo unassociated with a headache is suggestive of an asymmetry of neurotransmission.
The pathophysiology of MRV is unknown at this time. MRV may be caused by
- a spreading wave of depression and/or vasospasm in brain tissue
- neurotransmitter release in the peripheral or central balance (vestibular) system
- gene mutations related to calcium channel disturbances in the brain and the inner ear (such as those associated with hemiplegic migraine and episodic ataxia type II)
"During a migraine attack, there may be increased excitation in the trigeminovascular system which has been shown in animals to cause vasodilatation and plasma extravasation. Release of neuropeptides, including substance P, neurokinin A, and CGRP, may cause this neurogenic inflammation. CGRP and other neuropeptides may increase excitability of the inner ear vestibular receptors. Asymmetry of these neurotransmitters in migraine may be responsible for the symptoms of dizziness and vertigo."
MRV is quite variable in presentation i.e. the reason the condition is called "atypical migraine variant". It may be associated with a frank migraine headache such as that seen in "basilar migraine", or the episodic vertigo spell may be unassociated with a headache. If a headache occurs with the vertigo spell, it may occur before, during, or after the spell. The headache can be variable i.e. severe migraine type or dull type.
Other neurologic symptoms, in various combinations, may accompany the vertigo spell such as:
- ear pain (otalgia)
- ringing in the ears (tinnitus)
- ear fullness
- migratory scalp pain,
- nausea and/or vomiting
- heightened sensitivity to light (photophobia) or sound (phonophobia)
- visual changes (bright lights, zigzag lines, blurred vision)
- tingling around the mouth or hands/fingers (paresthesias)
- difficulty talking (dysarthria)
- facial numbness, limb numbness or weakness
- mental confusion (sometimes referred to by patients as foggy-headedness, fuzzy-headedness, or swimmy-headedness
The frequency of the episodic vertigo is variable. Patients may have spells every few years, months, weeks, or days. Triggers may or may not be able to be identified.
The duration of the episodic vertigo may be hours, days, a weeks or up to six months. A few rare patients may experience continuous vertigo or a sensation of great dysequilibrium
It is the author"s experience (EMK) that genuine hearing loss is not associated with MRV. In particular, fluctuating hearing loss is not associated with MRV but is associated with Meniere"s Disease or endolymphatic hydrops (in various forms). The presence or absence of fluctuating hearing loss is one sign that helps to differentiate MRV from other otologic conditions. There are rare, challenging patients that may have both Meniere"s Disease and MRV.
Patients who have MRV usually do not associate their spells of episodic vertigo with migraine disease even though they often have other associated neurologic symptoms. Similarly, physicians who examine patients with MRV often fail to associate the episodic vertigo and neurologic symptoms with a migraine etiology because symptoms of headache may be absent. Often, patients present to the emergency room with sudden, severe vertigo, are evaluated for a possible stroke, have a negative CT head scan for stroke, and are discharged with the diagnosis of "vertigo".
Patients with MRV usually have a past history of migraine headache. The headaches may have started in their late teenage years, slowly dissipated, only to re-emerge as vertigo without headache in their forties or fifties. Some patients will have had only a few "bad headaches" within six months of the MRV spells. The headache history is often quite variable.
Some women may begin to experience MRV due to hormonal changes particularly during peri-menopause or menopause. Treatment with estrogens may be related to MRV.
Patients with MRV may have experienced vertigo or motion intolerance during childhood. In fifty (50%) of cases, there is a positive family history of migraine disease (mother, father, siblings, etc.)
In order to diagnose MRV, all known causes of vertigo must be ruled out such as:
- Meniere"s Disease (endolymphatic hydrops)
- middle ear, mastoid, and brain infections
- head and ear trauma
- tumors of the ear, hearing nerve, and brain
- metabolic disorders
- endocrine disorders such as thyroid disease
- benign intracranial hypertension
- congenital abnormalities of the brain and brainstem (Chiari malformations, hydrocephalus, etc)
- demyelinating diseases (multiple sclerosis, etc.)
- autoimmune disorders (autoimmune inner ear disease, etc.)
- vascular disease and abnormalities (stroke, etc.)
- medication side-effects
- hormonal issues
- psychiatric conditions
- toxic exposures
- positional vertigo and benign paroxysmal positional vertigo
- superior semi-circular canal dehiscence syndrome
- traumatic perilymph fistulas (abnormal openings between the middle and inner ears)
In order to rule out the above conditions, it is usually necessary to have:
- basic hearing testing
- MRI and/or MRA head scanning, CT scanning, etc.
- blood tests (complete blood count, blood chemistry testing including blood glucose, thyroid testing, tests for autoimmunity (rheumatoid factor, ANA, 68 KD antibody, Antibodies to Type II collagen, etc.)
- special tests for syphilis (MHA-TP) and lyme disease (lyme titres)
- occasionally neurologic testing including auditory brainstem response testing (ABR), electronystagmography (ENG), electroencephalography (EEG)
- ophthalmologic examination of the eyes
- possibly a spinal tap (lumbar puncture) for cerebrospinal fluid analysis (CSF)
- a toxicology screen
With MRV, the above tests are usually normal with the exception of the ENG which may show decreased vestibular function in one or both ears. Similar ENG results may be seen in Meniere"s Disease.
Patients should have a complete physical examination by their family doctor and may need to have evaluation by: (1) an otologist who treats disorders of the balance system, and (2) a neurologist who specializes in migraine treatment.
The treatment of MRV is aimed at preventing the vertigo spells and neurologic symptoms and is different than the treatment for acute migraine headaches (ibuprofen, Naprosyn® 500 mg., Midrin®, steroids, Cafergot® oral or suppositories, Medihaler Ergotamine®, Ergostat® 2mg., Demerol®, 5-HT1A and 5-HT1B receptor agonists (Sumatriptan), and DHE 45). Keeping a vertigo and headache calendar may be beneficial in the diagnosis of MRV. "Sumatriptan (Imitrex®) and DHE 45 have proven effectiveness in migraine treatment. Proposed mechanisms of action include:
- blocking the neurogenic inflammation produced by antidromic electrical stimulation of the trigeminal afferents
- acting almost exclusively on serotonergic receptors (serotonergic agonists)
MRV may be treated with:
- avoidance of dietary triggers for migraines such as caffeine, chocolate, red wine, hard cheese, bananas, etc. (click to see a complete list: Headache I Diet)
- Beta blockers (propranolol, metoprolol)
- anticonvulsants (clonazepam),
- calcium antagonists (flunarizine)
- antidepressants (amitriptyline)
- riboflavin (vitamin B2) + magnesium aspartate or oxide
- a reduction or cessation of estrogen therapy
One recent study by Maione found that nearly 82% of patients diagnosed with MRV experienced a 50% reduction in the frequency of their episodic vertigo.
- Vestibular Dysfunction in Migraine. Glaxo FDA study, 1993.
- Maione A. Migraine-related vertigo: diagnostic criteria and prophylactic treatment. Laryngoscope, 2006, 116, 1782-1786.138.
- Cutrer FM, Baloh RW. Migraine-associated Dizziness. Headache, 1992, 32:300-304. (Classic article)
- Parker W. Migraine and the Vestibular System in Adults. Am J Otology, 1991, 12(1):25-33.
- Rassekh C, Harker LA. The Prevalence of Migraine in Meniere's Disease. Laryngoscope, 1992, 102:135-138.
- Welch KMA. Drug Therapy of Migraine. NEJM, 1993, 329(20):1476-1483.
- Stewart WF, Lipton RB, Celentano DD, Reed ML. Prevalence of Migraine Headache in the United States: relationship to age, income, race, and other sociodemographic factors. JAMA, 1992, 267(1):64-70.
- Woods RP, Iacoboni M, Mazziotta JC. Brief Report: Bilateral Spreading Cerebral Hypoperfusion During Spontaneous, Migraine Headache. NEJM, 1994, 331(25):1689-1692.
- Abu-Arafeh I, Russell G. Paroxysmal Vertigo as a Migraine Equivalent in Children: a population-based study. Cephalalgia,1995, 15:22-25.
- Liu GT, Schatz NJ, Galetta SL, Volpe NJ, Skobieranda F, Kosmorsky GS. Persistent Positive Visual Phenomena in Migraine. Neurology, 1995, 45:664-668.
- Bahmad F, et.al. Locus for Familial Migrainous Vertigo Disease Maps to Chromosome 5q35. Annals ORL, 2009, 118(9):670-676.
- Shin JH, Kim YK, et al. Altered brain metabolism in vestibular migraine: comparison of interictal and ictal findings. Cephalalgia 2013;August 5:epub ahead of print.
To learn more about MRV, please contact our office at (336) 273-9932.
January 18, 2014