Migraine vertigo
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Understanding Migraine-Associated Vertigo: Symptoms, Diagnosis, and Treatment
Prevalence and Comorbidity of Migraine and Vertigo
Migraine and vertigo are prevalent conditions, affecting approximately 14% and 10% of the general population, respectively. Interestingly, the comorbidity rate of these two conditions is higher than expected, with about 3.2% of the population experiencing both, suggesting a significant association between them . This excess comorbidity can be attributed to vestibular migraine (VM), where vertigo is a symptom of migraine, and other vertigo syndromes like Menière's disease and benign paroxysmal positional vertigo (BPPV) that are more common in migraine sufferers .
Symptoms and Diagnostic Criteria of Vestibular Migraine
Vestibular migraine presents with episodes of spontaneous or positional vertigo that can last from seconds to days. These episodes may or may not be accompanied by headaches but often include other migraine-related symptoms such as photophobia, phonophobia, and auras . The International Classification of Headache Disorders, 3rd edition (beta version), has updated the diagnostic criteria for VM, making it easier to identify this under-recognized condition.
During acute VM attacks, patients may exhibit central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. However, vestibular testing during symptom-free intervals usually shows minor and nonspecific findings . The pathogenesis of VM is not fully understood, but it is believed that migraine mechanisms may interfere with the vestibular system at various levels, including the labyrinth, brainstem, and cerebral cortex .
Frequency of Dizziness and Vertigo in Migraine Phases
Dizziness and vertigo are common symptoms during both the prodromal and headache phases of migraine. Studies show that during the prodromal phase, 9.0% of individuals with migraine report dizziness, and 3.3% report vertigo. These numbers increase significantly during the headache phase, with dizziness reported by 35.7% and vertigo by 33.9% of individuals. This indicates that these symptoms are more frequent during the headache phase compared to the prodromal phase.
Challenges in Diagnosis
Diagnosing migraine-associated vertigo can be challenging due to the variability of symptoms among patients and the overlap with other conditions like Menière's disease and BPPV. Migrainous vertigo is the most common cause of spontaneous recurrent vertigo, yet it is not included in the current International Headache Society classification of migraine . The lack of specific diagnostic tests and the nonspecific abnormalities found in vestibular testing further complicate the diagnosis .
Treatment Approaches
The treatment of vestibular migraine generally follows the protocols for managing migraine headaches. This includes dietary and lifestyle modifications, as well as medical treatments with beta blockers, calcium channel blockers, and tricyclic amines. Some studies suggest that acetazolamide and lamotrigine may be more effective for vertigo attacks than for headaches . Vestibular rehabilitation has also shown to be beneficial in managing vestibular symptoms .
A retrospective review of 89 patients with migraine-related dizziness and vertigo found that individualized treatment plans, which included dietary changes, medication, physical therapy, lifestyle adaptations, and acupuncture, were effective in controlling vestibular symptoms in a significant majority of patients. This highlights the importance of a tailored approach to treatment based on individual symptoms and comorbidities.
Conclusion
Migraine-associated vertigo is a complex and often under-recognized condition that significantly impacts those who suffer from it. The high comorbidity rate of migraine and vertigo underscores the need for better diagnostic criteria and more effective treatment strategies. While current treatments are adapted from migraine headache management, there is a need for more targeted therapies and controlled clinical trials to validate their efficacy. Understanding the intricate relationship between migraine and vertigo can lead to improved patient outcomes and quality of life.
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