Migraine-associated vertigo

In Neurologic Clinic’s publication, Migrainous Vertigo , Lempert and Neuhauser begin with a story taken from Paul Auster’s novel, Mr. Vertigo:

I felt a little light-headed, but it seemed that the crisis had passed. But then I stood up and it was precisely then that the headache returned, ripping through me with a blast of savage, blinding pain. I tried to take a step, but the world was swimming undulating, like a belly dancer in a fun-house mirror, and I couldn’t see where I was going. By the time I took a second step, I had already lost my balance. If the master hadn’t been there to catch me I would have fallen flat on my face again.

Migraine-associated vertigo is dizziness associated with a migraine headache condition.(Kayan and Hood (1984) found “an increased frequency of vertigo in people with migraines versus people with tension headaches.”) Living found that 6 out of 60 migraine patient exhiited attacks of vertigo.

The association between migraine and dizziness dates back 150 years when Edward Living found that 6 out of 60 migraine patients exhibited attacks of vertigo. Since dizziness is one of the most common reasons people consult physicians, the diagnostician must determine whether the dizziness and headache are related and then, whether the dizziness is a manifestation of migraine, or whether they co-exist by chance.

Epidemiology

Migraine causes far more vertigo than any other condition.

Nearly 13% of the adult population of the United States has migraine. The distribution differs between male and females. At all ages, about 5% of men have migraine (Stewart, 1994; Lipton et al, 2002). Women of childbearing age have a much higher prevalence, jumping up to roughly 10% at the onset of menstruation, and increasing to nearly 30% at the peak age of 35 years. At menopause, rates of migraine abruptly decline in women back to roughly 10%.

According to medical practices treating migraines, 27-42% of patients report episodic vertigo. About 36% of these experience vertigo during headache-free intervals. The remainder experience vertigo preceding onset or during the headache itself.

Most studies report that about half of patients with migraines suffer with motion sickness compared to 5-20% for control groups. Syncope can also accompany migraine, offering another entirely separate mechanism for dizziness in migraine - hypotension mainly attributed to vasopressin.

Pathophysiology

The pathophysiology of migraine is not completely understood, nor is that of migraine-associated vertigo. However, both central and peripheral defects have been observed. Timothy Hain, M.D. of Chicago Dizziness and Balance at Northwestern University proposed an updated theory of pathophysiology at the Spring 2008 conference for Migraine-Associated vertigo.

According to his theory, we start with a patient who has a hyperexcitable brain. Add to that, environmental events which push the individual’s brain past a threshold, leading to electrical changes (cortical spreading depression (CSD), which causes aura. CSD also stimulates the trigeminal nucleus caudalis (TNC), and causes the release of inflammatory neuropeptides (CGRP) which produce vasodilation and sensitization (allodynia) in the trigeminal nerve circuit. Pain and sensitization lead to a positive feedback loop.

Why is vertigo a manifestation of migraine? John Carey, M.D. of Johns Hopkins, presented the following hypothesis at the Spring 2008 Conference on Migraine-Associated Vertigo: “The blood vessels of the cochlea and vestibular labyrinth are innervated by branches of V1 of the trigeminal nerve.” This causes plasma extravasation with substance P in the stria vascularis and cochlear tissues.

According to Hain, an asymmetric release of neuropeptides result in the sensation of vertigo; if the release is symmetric, the patient feels an increased sensitivity to motion due to an increased vestibular firing rate during head movements. It has also been suggested that CGRP and other neuropeptides produce a prolonged hormone-like effect as these diffuse into the extracellular fluid. “This may explain the prolonged symptoms in some patients with migraine-associated vertigo, as well as the typical progression of persistent spontaneous vertigo followed by benign positional vertigo and then motion sensitivity.”

Serotonin has also been found to be important in the development of migraine-associated vertigo.

Brantberg, Trees & Baloh proposed in 2005 that there are multiple migraine-associated vertigo syndromes and multiple genes and environmental factors underlying them. Their study showed that typical migraine headaches progressed over time into attacks of vertigo and about half of the patients had visual aura. Only half of the patients had ever had a headache simultaneous with an attack of vertigo.

Symptoms and Syndromes Associated with MAV

Vertigo is a vestibular disturbance whereas dizziness is not. Vertigo includes a feeling of rotation and/or illusory sensations of motion. Dizziness is a feeling of light-headedness, giddiness, drowsiness, and/or faintness.

“In patients with migraine-associated vertigo, the first symptoms to appear are typically headache, with vertigo beginning several years later.”

Migraine-associated vertigo may manifest as episodic rotational vertigo (with or without nausea and vomiting), positional vertigo, constant imbalance, movement-associated dysequilibrium, illusory self or object motion, head motion intolerance, and/or light-headedness. Migrainous symptoms during vertigo may occur, such as photophobia, phonophobia, osmophobia, and/or visual or other auras. There is usually minimal or no nystagmus, which differentiates it from other peripheral vestibular syndromes. If nystagmus does present, it is often directed vertically.Tinnitus and hearing loss may occur. Symptoms may appear during the prodrome, during the headache, or often during headache-free intervals.

Benign Paroxysmal Vertigo Syndrome of Children

Benign paroxysmal vertigo syndrome of children is an example of migraine-associated vertigo in which headache does not occur.

Basilar Migraine (BAM)

Basilar migraine consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields or both eyes, diplopia, bilateral paresthesias, paresis, decreased consciousness and/or loss of consciousness) followed by throbbing headache. Auditory symptoms are rare. However, a study showed a fluctuating low-tone sensorineural hearing loss in more than 50% of patients with BAM with a noticeable change in hearing just before the onset of a migraine headache. The attacks of vertigo are usually concurrent with the headache and the family history is usually positive. The diagnostician must rule out: TIAs, and paroxysmal vestibular disordered accompanied by headache.

Cyclic Vomiting

This is a syndrome in which people suddenly develop vomiting, usually without headache or hearing symptoms.

Familial Syndromes

There is also a familial vestibulopathy, familial Benign Recurrent Vertigo (BVR), where episodes of vertigo occur with or without migraine headache. Testing may show profound vestibular loss. The syndrome responds to acetazolamide. Familial hemiplegia migraine has been linked to mutations in the calcium channel gene. (Ophoff et all, 1966).

Vertigo Syndromes Associated with Migraine

BPPV

Migraine is commonly associated with benign paroxysmal positional vertigo (BPPV), the most common vestibular disorder in patients presenting with dizziness. The two may be linked by genetic factors or by vascular damage to the labyrinth.

Ménière’s disease

There is an increased prevalence of migraine in patients with Ménière’s disease and migraine leads to a greater susceptibility of developing Ménière’s disease. But they can be distinguished. Migraine-associated vertigo may go on for days, weeks, months, even years, whereas Ménière’s disease never goes on longer than 24 hours.

Motion sickness

Motion sickness is more prevalent in patients with migraine.

Psychiatric syndromes

Dizziness and spinning vertigo are the second most symptom of panic attacks, and they can also present as a symptom of major depression. Migraine is a risk factor for developing major depression and panic disorder and vice versa.

Diagnosis

Headache is not required to make the diagnosis of migraine-associated vertigo.

No diagnostic tests specific for migraine-associated vertigo exist. Careful history-taking is essential.

Lembert and Neuhauser propose criteria for definite and probable migraine-associated vertigo.

Definite migraine-associated vertigo:

A) Episodic vestibular symptoms of at least moderate severity. B) Current or previous history of migraine according to the 2004 criteria of the HIS (Headache International Society) C) One of the following migrainous symptoms during ≥ 2 attacks of vertigo: migrainous headache, photophobia, phonophobia, visual or other auras. D) Other causes ruled out by appropriate investigations.

Probable migraine-associated vertigo:

A) Episodic vestibular symptoms of at least moderate severity. B) One of the following: 1) Current or previous history of migraine according to the 2004 criteria of HIS. 2) Migrainous symptoms during vestibular symptoms. 3) Migraine precipitants of vertigo in more than 50% of attacks: food triggers, sleep irregularities, hormonal change. 4) Response to migraine medications in more than 50% of attacks. C) Other causes ruled out by appropriate investigations.

They add, in patients with a clear-cut history, no vestibular tests are required.

Other historical criteria which are helpful in making the diagnosis of migraine-associated vertigo are vertiginous symptoms throughout the patient’s entire life, a long history of motion intolerance, sensitivity to environmental stimuli, illusions of motion of the environment, and vertigo which awakens the patient.

Treatment

The Abortive Approach

Abortive Medications

The vasoconstrictors DHE, ergotamine, isometheptene constrict blood vessels of the brain. Triptans, such as rizatriptan (Maxalt), eletriptan (Relpax), sumatriptan (Imitrex), zolmitriptan (Zomig), and naratriptan (Amerge) bind to serotonin receptors, reducing pain by blocking TNC and reducing secondary sensitization. They are highly effective with minimal side effects. However, they may cause rebound.

The Prophylactic Approach

The Migraine Diet

The first line of prophylactic approach is strict adherence to the “migraine diet.” David Buchholz, M.D., in his Book, Heal Your Headache, gives a comprehensive version of the diet. In short, it is recommended to quit all food triggers for three months, in order to rid the body of all metabolites. These foods include caffeine, chocolate, MSG, processed meats and fish, fermented dairy products, nuts, alcohol and vinegar, citrus fruits, dried fruits along with some other fruits, some vegetables, especially onions, yeast, and aspartame. The three major substances thought to be causative triggers are histamine, phenylethylamine, and tyramine.

If after three months, there is no clear improvement, the patient will move on to prophylactic medications. If, however, there is significant help with the removal of trigger foods, the job is to add back foods, one at a time, to find out which is the culprit.

Prophylactic medications

According to Dr. Hain, the mechanisms of most of the prophylactic medications are not well understood, but they all work about 75% of the time and take weeks to months to work. Dr. Hain categorizes prophylactic medications as follows:

CSD blockers: Anticonvulsants

These probably raise the threshold for CSD and include the following:

Topiramate (Topamax) is about 75% effective. Side effects include, but are not limited to, weight loss, hair loss, speech disturbance, difficulty in word-finding and tingling in the hands and feet.

Other anticonvulsants used include: gabapentin (Neurontin), divalproex sodium (Depakote) and levetiracetam (Keppra).

Mysterious mechanism agents: Beta blockers and L-channel calcium channel blockers

Beta blockers are 75% effective though the mechanism of action is unclear. Any beta blocker will work: propranolol, metoprolol, or atenolol. Side effects include fatigue, slow pulse and hypotension. It takes one month for them to work.

L-channel calcium channel blockers including:

Verapamil is 75% effective. The mechanism is not well understood, although it possibly blocks TNC or possibly relates to the calcium channel gene. It takes two weeks to work. The main side effect is constipation.

Neurochemical modulators: Antidepressants

Venlafaxine (Effexor) is 80% effective. The mechanism is not very clear. Effexor is an SNRI and SSRI. It is very useful in managing the sensory amplifications seen in migraine. It is inexpensive. The side effects are minor. However, high doses have a difficult withdrawal syndrome.

Tricyclics – amitriptyline/nortriptyline. Dr. Hain calls these “messy agents.” They work as central antihistamines, affecting norepinephrine and serotonin receptors.

Supplements

Riboflavin has been rigorously studied and has demonstrated a reduction of migraine days and hours by 44%, although with no reduction in intensity of the headache.

Support

Support is important for people suffering with migraine-associated vertigo. It is a life-limiting illness which goes on for days, weeks, months and even years. Those that are intractable to treatment may feel helpless and hopeless. Unfortunately, the worst sufferers, who need psychological counseling the most, cannot leave the house, and sometimes even the bed. For them, the only source of support may be on-line support groups.