What is Migraine-Associated Vertigo ?
Vertigo is a feeling of movement or spinning, even when you’re not actually moving or your surroundings aren’t changing. This can sometimes be linked with migraines, which is when severe headaches occur. When vertigo is the main feature of your migraines, it’s often called vestibular migraine (VM). This condition was previously known by different names such as migraine-associated vertigo and migraine-related vestibulopathy.
In VM, people often describe a feeling of moving back and forward. These symptoms can occur without the typical headache usually associated with migraines, making diagnosis challenging. Thus, a thorough review of your health history and comprehensive medical examination are key to correctly identify this condition.
In a widely accepted classification system for headaches, only two types of migraines included vertigo as a symptom. The particular criteria for these types of migraines have recently been updated by the International Headache Society.
To confirm a diagnosis of definite VM, you must have at least five occurrences of moderate or severe vertigo lasting between five minutes and three days. You also need to have a history of migraines and evidence of migraine-like symptoms in at least half your vertigo episodes. These symptoms could involve headaches with certain features, sensitivity to light or sound, or visual disturbances. Importantly, your symptoms should not be better explained by another condition affecting balance or a different type of headache disorder.
To be diagnosed with probable VM, you need at least five episodes of significant vertigo, but only one of the specific migraine-related criteria need to be met. Again, your symptoms should not be more accurately caused by another balance or headache disorder.
In 2018, the diagnostic rules for VM were updated. The key part of the new criteria is having at least five bouts of moderate to severe vertigo lasting from five minutes to three days.
What Causes Migraine-Associated Vertigo ?
There isn’t a lot of clear evidence about what exactly causes vestibular migraines (VM), a type of migraine that also affects balance. However, genetics seem to play a significant role in whether or not someone is likely to get migraines, including VM.
In fact, recent large-scale genetic studies have pinpointed specific genes that can make someone susceptible to migraines. These include genes known as PRDM16, TRPM8 and LRP1. Further studies indicate that VM can be passed down through the generations via an inherited genetic trait linked to a specific region on our chromosomes, identified as 5q35. In one large family, most members experienced headaches followed by dizziness within 15 to 20 years after the first migraine episode. Some other studies have pointed to links to regions on chromosomes 11q or 22q12.
Intriguingly, in the same family affected by VM, while some members experienced normal migraines, others suffered from vestibular migraines or a condition called benign paroxysmal vertigo of childhood, a type of disorder causing sudden, brief spells of dizziness in children. These varying symptoms suggest that the way in which VM presents can differ among individuals, even within the same family carrying the gene. This means that the gene for VM is dominant, but its expression may vary.
Various disorders related to the balance mechanism in the inner ear, such as Meniere syndrome or benign paroxysmal positional vertigo (BPPV) – a disorder arising in the inner ear that causes episodes of dizziness, are seemingly associated with VM. These links between VM and inner ear balance disorders emphasize the complicated connection between migraine-related symptoms and problems with balancing mechanisms in the inner ear.
Risk Factors and Frequency for Migraine-Associated Vertigo
Migraines are a health issue that affects around 12% of the population, with 6% of adult men and 18% of adult women experiencing it. A special type of migraine, called VMs, is noted in about 1% of the population and is a common reason for episodic migraines.
VMs are mostly seen in adulthood, especially among females, who are five times more likely to have it compared to males. Vertiginous symptoms, a type of dizziness, typically start around the age of 37 for females and 42 for males. Migraines usually begin before the onset of vertigo, with headache symptoms starting on average at 28 years old, while dizziness generally shows up at around age 49.
- Migraines affect 12% of the population, 6% of adult men and 18% of adult women.
- VMs, a type of migraines, occur in about 1% of the population and are often the cause of episodic migraines.
- VMs are mainly seen in adults, especially among females who are five times more likely to have them than males.
- The average age for onset of vertigo symptoms is 37 for women and 42 for men.
- People generally start experiencing migraines before vertigo, with headaches starting at about age 28 and dizziness appearing at around 49.
Signs and Symptoms of Migraine-Associated Vertigo
Vestibular migraines (VM) are a health condition where individuals have symptoms such as dizziness, a false sense of motion, an altered sensation despite normal motion, imbalance, and disorientation. This can be coupled with discomforts like lightheadedness, a feeling of heaviness in the head, tingling, a rocking sensation, increased sensitivity to motion sickness, and hearing issues. Notably, about 30% of people diagnosed with VM may not have experienced headaches. The type of motion sensation commonly noted in cases of VM is a “to-and-fro” motion, but this can be varying in duration, which might make diagnosis difficult.
The pattern of these vestibular symptoms during headache episodes isn’t consistent. Vertigo and headaches usually do not happen at the same time; it’s quite rare for both symptoms to occur simultaneously. Most patients first seek help from primary care providers and try to manage the symptoms. If the symptoms persist or come back, patients often consult with head and neck specialists. Meniere’s disease is often considered initially based on the symptoms. But a final diagnosis of VM is made when there’s no low-frequency hearing loss in hearing tests, or no response to typical treatments used for Meniere’s disease.
Vestibular migraines can be persistent and can be related to a woman’s menstrual cycles. Research reveals that close to half of those diagnosed with probable VM become definite VM, based on specific diagnostic criteria. The same research shows that nearly 30% saw an increase in the frequency of attacks over a nine-year period, and around half reported a reduction. Almost 90% of those with VM still had vertigo attacks after nine years. Over time, it becomes more common for these people to have cochlear problems such as fullness in their ears, tinnitus, and hearing loss during vertigo spells.
Testing for Migraine-Associated Vertigo
When diagnosing Vestibular Migraine (VM), understanding your health history is crucial because there are no specific tests or scans that can definitively confirm this condition. However, certain findings in Magnetic Resonance Imaging (MRI) tests, which are scans that use magnetic fields to create detailed images of the body, have been linked more to people with VM compared to others of the same age and gender. To note, these tests are generally used to learn more about migraines, and research focused specifically on VM is limited.
There are tests to evaluate the functionality of the ears and the nerves that connect it to the brain (vestibular testing and neurotologic exams). However, these tests usually don’t provide clear-cut answers in people diagnosed with VM alone. It’s worth noting that exceptions may be seen in people who have other conditions, such as Meniere syndrome or Benign Paroxysmal Positional Vertigo (BPPV), as they may have abnormal test results more frequently.
Research has indicated that during certain tests like caloric testing (a procedure that studies eye movements to test balance functions), VM patients may show abnormal responses such as under- or over-reactive vestibular responses. Similarly, VM patients may present abnormalities in the sacculocollic pathway (a chain of communication between the ear and the neck muscles) according to one study. These abnormalities, however, are not unique to VM and hence it doesn’t provide conclusive evidence.
In the end, diagnosing VM relies mainly on an in-depth review of your health history, family history of migraines, and history of vertigo during childhood. Your doctor will also work to rule out other conditions that affect balance and spatial orientation before confirming a VM diagnosis.
Treatment Options for Migraine-Associated Vertigo
Vestibular migraines, a condition that causes symptoms of vertigo and headaches, currently have no universally accepted specific treatment. It can be hard for doctors and patients to understand this condition, as the vertigo symptoms often occur without headaches. This can delay or even prevent treatment for some people.
There have been isolated studies that suggest certain medications, such as triptans, could help during the acute vertigo episodes associated with this condition. However, a majority of the research, including Sargent’s study, suggests that triptans are not a successful treatment for vestibular migraines. Furthermore, there’s no strong evidence to suggest that triptans can alleviate vertigo symptoms. Similarly, certain medications like triptans and calcium channel blockers (medications that relax and widen blood vessels) do not seem to shorten or prevent migraines. Therefore, currently, the most common treatment for acute vestibular migraines includes antiemetic and antivertigo therapies, and sometimes benzodiazepines (a type of medication known as tranquilizers).
A new treatment method that involves noninvasive vagal nerve stimulation (nVNS), which is a treatment administered by the patient without any surgical procedure, has shown promise in managing acute vestibular migraines. It is safe to use and has minimal side effects.
For prevention, current recommendations emphasize lifestyle adjustments, such as avoiding specific foods that may trigger migraines, improving behaviors, and maintaining good sleep routines. A past study indicated that stopping caffeine consumption improved symptoms in about 15% of patients. However, the relief was not complete, and most patients required more medical intervention. The same study also found that about 75% of people with vestibular migraines found substantial relief from lifestyle changes combined with certain medications like nortriptyline or topiramate, without further treatment needed.
In a recent trial, treatments like venlafaxine, flunarizine, and valproic acid showed promise in preventing vestibular migraines. Each of these treatments seemed to have different benefits. For instance, venlafaxine was helpful in addressing emotional symptoms. Both venlafaxine and valproic acid were effective in reducing the number of vertigo attacks, but valproic acid seemed less successful in reducing vertigo severity.
The American Headache Society and the American Academy of Neurology recommend several treatments for managing episodic migraines, including a variety of medications including topiramate. Although only topiramate has been specifically studied for treating vestibular migraines, doctors can consider these various medications as potential treatment options. Other options might include amitriptyline (a medication that treats depression, nerve pain, and used to prevent migraines) and calcium channel blockers. Doctors may also need to take into account any other medical conditions a patient has when considering treatment options.
Recently, monoclonal antibodies that target a certain protein called calcitonin gene-related peptide (CGRP) have shown potential in treating vestibular migraines. However, there are challenges with this treatment, including the high cost and difficulties in getting insurance approval.
Physical therapy may also be beneficial in addressing symptoms associated with vestibular migraines, such as anxiety and visual dependence. Patients with imbalance symptoms at times when a migraine is not occurring may benefit from vestibular rehabilitation therapy.
At this time, surgery is not recommended as it may make vertigo symptoms worse, especially in patients with Meniere’s disease. People diagnosed with vestibular migraines are advised to explore non-invasive and medication treatments under their doctor’s guidance, emphasizing symptom management and improved quality of life.
What else can Migraine-Associated Vertigo be?
When trying to determine if someone has vestibular migraines (VM), doctors consider several other conditions as possible causes of symptoms. Some of these conditions include:
- Meniere Syndrome: Many people with Meniere syndrome also exhibit symptoms of VM. Studies show that almost half the patients with Meniere syndrome could either have VM or show some VM-like traits. Further research has linked Meniere Syndrome with VM suggesting that these two conditions might be related. However, correctly diagnosing these conditions is crucial as they share overlapping symptoms, leading to diagnostic confusion and patient distress.
- Benign Paroxysmal Positional Vertigo (BPPV): The link between BPPV and VM is still unclear. However, studies have shown that people with BPPV often have a higher incidence of motion sickness or a history of migraines than the general public. Therefore, if a patient shows symptoms like vertigo, nausea and headaches, VM could be a possible diagnosis.
- Migraine Anxiety-Related Dizziness (MARD): MARD is characterized by repeated instances of dizziness that lead to severe anxiety. It is diagnosed by looking for symptoms related to anxiety, migraines, and balance disorders. All aspects including anxiety management, migraine treatment and balance disorder interventions must be considered.
- Other considerations: In kids, vertigo can often be related to migraines. Other potential diagnoses to consider before confirming VM are Meniere syndrome, BPPV, psychogenic dizziness, and spinocerebellar ataxia.
In every diagnosis, it’s crucial to consider all possibilities to ensure accurate diagnosis and treatment planning.
What to expect with Migraine-Associated Vertigo
The future health outcome for these patients remains uncertain. However, based on everyday experiences and informal advice, it appears that the condition often comes back. This uncertainty underlines the importance of continued research and creating personalized care plans. These care plans are being developed with the aim of effectively dealing with the frequent return of this condition.
Possible Complications When Diagnosed with Migraine-Associated Vertigo
Observations in medical practice have found different levels of disability and reaction to treatments among people with vestibular migraine (VM). It’s essential to create individual treatment plans that take into account each person’s specific symptoms and responses to therapies. By doing this, we can improve the quality of life for those dealing with VM.
Individualized Treatment Importance:
- Not everyone with VM reacts the same to treatments
- Each person with VM has a unique set of symptoms
- Specific treatments work differently for each person
- Improving quality of life requires personalized treatment plans
Preventing Migraine-Associated Vertigo
Convincing a patient to accept the diagnosis of Vestibular Migraine (VM), a type of migraine that includes a problem with the way balance is controlled by the brain, can be difficult. This difficulty can lead to delayed or no treatment at all. The tough part is because the symptoms – dizziness and headaches – don’t always happen at the same time, which might be hard for both the doctor and patient to make sense of.
For effective care, it’s important for patients to consistently take their prescribed medication and understand the necessity for regular check-ins with their doctor. Frequent communication and check-ups are key to adjust treatments if needed and to manage any changes in symptoms correctly.
