Vestibular Migraine
Vestibular migraine that is seen with migraine and vestibular system disorders is not well-known even by doctors today. Patients experience these symptoms and can not be properly diagnosed due to the low incidence and recognition level of vestibular migraine in the population. However, there are brand new and advanced examination methods today. It is highly easy to distinguish vestibular migraine from the other vestibular system disorders with these examination methods. Detailed tests such as VHIT (Video Head Impulse Test) and VEMP (Vestibular Evoked Myogenic Potentials) and recent FMRI imaging methods providing clear information about brain systems are very important for the diagnosis. Treatment should be approached from a few points; while the impairment in vestibular system is rehabilitated with maneuvers and new generation drugs appropriate for the condition, migraine treatment should be carried out on the other side. R-TMS treatment is also very beneficial for these patients.
Properly discovering the migraine itself is the key point to solve the problems while identifying vestibular migraine.
Migraine is probably related to both abnormal discharges in the cells in brain and constriction of the walls of blood vessels in and around the brain, because of headache. No matter how the migraine is extremely similar to a painful headache image, it is usually more than a headache. In fact, headache can sometimes be insignificant or inexistent. Migraine patients know that it is triggered by a number of stimuli before it arises. If there is a visual phenomenon, it is important for migraine. This might be either light or noise. Migraine can be triggered sometimes by visual aura such as flickering light spots, scrolling light texts or flashing light alarms. Headache is likely to come out approximately 15 minutes after this visual phenomenon.
We recognize that migraine has many types and some of them produce symptoms related to inner ear balance and mechanisms. We also acknowledge that migraine symptoms can be seen independently from headache. For example, some patients may experience a visual sound without headache, some patients may have balance and hearing problems other than headache. In some cases, particularly during adolescence and young adulthood period, headache might occur; but while headache complaints disappear, other symptoms related to migraine might sustain. While some patients have headache before and after vestibular (balance) symptoms, many patients have only occasional headache or migraine, and might not occur with vestibular symptoms at the same time. In fact, vestibular symptoms and headache are not seen together in the majority of vestibular migraine patients.
Classical Migraine Symptoms
Severe hemicranial throbbing and headache, nausea and vomiting, hypersensitivity against light and noise, necessity of a dark and quite room to fall into sleep.
Although these findings commonly exist in migraine patients, many people are not aware that there is a connection between migraine and inner ear and brain mechanisms that affect hearing and balance.
Diagnosis of migraine
1. If accompanied by headache or not
2. If severity of pain causes loss of function in daily works
3. If photophobia accompanies to the pain.
If two of these 3 questions are answered yes, migraine can be diagnosed by 81% sensitivity and 75% specificity. This test can be used in cases of difficulty in diagnosing migraine.
Hearing and vestibular findings in vestibular migraine;
Migraine has xxx, and vertigo has 7% proportion in the adult population. While coincidence of migraine and vertigo is expected at 1%, it has been found to be 3.2% for combination of vestibular vertigo and migraine. It causes loss of workforce and life quality. It is reported to be recognized little even among the physicians.
Vestibular Symptoms: Vertigo, Imbalance, Dizziness, Instability, Hypersensitivity against movement, Hearing findings, Hearing suppression, Aural fullness, Tinnitus
How vestibular migraine (VM) is diagnosed?
It is necessary for vestibular migraine diagnosis that migraine is diagnosed according to the 2004 criteria and vertigo episodes are not sourced from other reasons. Moderately recurrent vertigo episodes must be accompanied by at least two photophonophobia (light and noise sensitivity) and visual and other auras for a precise VM diagnosis. For a possible VM diagnosis, during moderately recurrent vertigo episodes and vestibular symptoms, migraine-like complaints must be caused by migraine triggers in 50% of the episodes or more than 50% of the episodes must respond against migraine medicines.
Vestibular migraine is diagnosed with an adequate interrogation after the most frequent vertigo reasons are excluded, for the patients applying with vertigo complaint with a precise migraine diagnose and the patients having headache but not diagnosed with migraine. Neurological and neuro-otological assessments of vestibular migraine patients are usually normal in the absence of complaints.
VM can be seen at any age, and more frequent in women. Migraine starts earlier in the majority of patients. 40-70% of the patients complaints of positional vertigo, but this positional vertigo is not BPPV. They have intolerance against head movements. Recurrent imbalance which is triggered or deteriorated by head movements are additional findings of a vestibular problem. The duration of vertigo can be extended from seconds to hours, or sometimes to days. Recovery after episodes may take several weeks in some patients. For the 30% majority of patients, vertigo last 5-60 minutes like typical migraine aura. Some episodes are accompanied by headache, some are not; some patients have never headache together with vertigo. It should be investigated in details whether vertigo is accompanied by photo/phonophobia, visual and other auras in the cases without headache. Hearing loss and tinnitus are not common in vestibular migraine, but some reported cases are present. It is very difficult to make a diagnose for the patients who don't have a precise migraine diagnose. Car sickness and migraine history in the family should necessarily be investigated for these patients. In the patients applying to clinics with vertigo complaints, migraine diagnosis can be made by the physician who examines the patient for vertigo. Although patients have typical migraine headache for years, they may not have been diagnosed.
Vestibular migraine in children
There have been some clues about migraine and vertigo relation also before the studies in recent years. Benign paroxysmal vertigo of childhood and benign recurrent vertigo of adults are well known migraine equivalents.
Benign paroxysmal vertigo of childhood; is the table of imbalance attacks, anxiety, frequent nystagmus and vomiting. It is seen as a repetitive table in healthy children. Migraine has been shown to develop later in these children after their vertigo episodes are terminated. Studies report that migraines are doubled in first-degree relatives of these children.
What are the compromising factors of vestibular migraine?
Although we are not completely capable of understanding the reasons of migraine, we know that a number of factors, including the following, can stimulate and compromise it:
Hypoglycaemia (low blood glucose), Stress and altered sleep patterns, Diet, Chocolate, Red wine, Caffeinated coffee, Soda, Cheese, Monosodiumglutamate (MSG), Dispositions and factors about migraine, Women tend to get migraine more than men. Symptoms usually worsen during menstruation period, Family history- migraine tends to transfer along family members.
Distinctive diagnosis in vestibular migraine:
It is necessary to make a correct diagnosis and distinctly diagnose the other situations which may cause similar indication. Other diseases, for example:
Benign Paroxysmal Positional Vertigo (BPPV), Meniere's Disease (also known as endolymphatic hydrops), Temporary ischemic episodes in the brain (microvascular occlusions) or small vessel bleeding, Internal ear fluid problems, Vestibular nerve irritation
Remarkable points in vestibular migraine:
Natural preventive measures should additionally be taken against vestibular migraine. Certain foods that can trigger migraines such as chocolate, red wine, cheese, caffeine and monosodiumglutamate (MSG) should be avoided.
Doing exercise and Stress Management is important. When migraine is associated with menstrual periods, it may be helpful to limit salt intake during menstruation.
Attention for the psychological consequences of the disorder is necessary with appropriate medications and consultation, as in every chronic and unpredictable vestibular disorders. The right combination of diet, exercise and medication (if necessary) will lead symptoms to be relieved and return to a normal life style for almost all patients.
