Is There A Link Between Migraine And Meniere's Disease ?

Is There A Link Between Vestibular Migraine And Meniere’s Disease?

 Anatomy.

The word “vestibule” comes from a part of the inner ear—the “vestibule.”  In Latin the word means “an entrance hall.”  The vestibule is the central par of the bony labyrinth in the inner ear, situated medial to the eardrum (tympanic membrane), behind the cochlea and in front of the three semicircular canals.  It connects to the brainstem through the eighth cranial nerve at the “vomit center” of the brain in the brain stem. 

 In the inner ear the semicircular canals respond to rotational movements (angular acceleration); and the utricle and saccule respond to changes in the position of the head with respect to gravity (linear acceleration).

Tne Inner Ear

Tne Inner Ear

 Definition of vertigo.

Migraine has a brain stem generator in the periaqueductal grey part of the mesencephalon near where labyrinthine fibers from the inner ear interconnect.  Migraine and vertigo have had a long, somewhat circumspect, and private relationship.  Neurology textbooks for the last 50 years have all listed vertigo under the long list of symptoms associated with migraine.  There is a large body of literature about the subject.   

Vertigo is a hallucination of movement that comes from the Latin root word which means “to turn” and is likened to the feeling one has after spinning around a number of times and then stopping.  It is what one feels on the playground after getting off of a merry go round.  Although usually rotary in motion with the patient at the center, vertigo in its broadest definition can be expanded to be “the perception of motion on the part of the patient.”  Thus, vertigo can be non-rotary, and include a sense of linear or up and down movement.  Vertigo may originate in the vestibular branch of the eighth cranial nerve in the “inner ear” where it is called “peripheral” or “end organ” or in the brain--usually in the cerebellum or brain stem--where it is referred to as being “central.”

Vertigo

Vertigo

Dizziness is a much less precise medical term that has multiple causes and does not localize to a specific area of the brain.  Dizziness may be described by the patient as “light-headed, giddiness, near faintness, swimmy headed, or unsteadiness,”  Dizziness has a large differential diagnosis and may be due to inner ear inflammation, hypoglycemia, electrolyte imbalance, low blood pressure, decreased heart output, anemia, anxiety or panic disorder, hyperventilation, medication effect, or many other causes.

On close questioning, most patients can differentiate between vertigo and migraine.  Complicating this discussion is the fact that the occurrence of dizziness in the general population is over 20%.  However, patients who have migraine with aura have significantly more dizzy spells than non-headache subjects.  Dizziness is strongly associated with functional medical problems.

 Motion sickness.

Another interesting and well-known link to migraine is motion sickness which usually comes on in childhood and improves somewhat with ageing.  The symptoms of motion sickness may be nausea, dizziness, vertigo, sweating, or headache.  Commonly children experience this in the back of the car when riding.  It also occurs with reading in the car, participating in amusement park rides--especially rides with fast circular motion--and on boats and airplanes.  Most studies report that about 60% of patients with migraine have motion sickness, while only 5-20% of persons without migraine get motion sickness.

Medical practices that specialize in migraine find that 27-42 % of patients report episodic vertigo.  About 36% of these migraineurs get vertigo when they have no headache, while many others get vertigo either just before or during the headache.  Migraine with aura patients have a higher incidence of vertigo during the headache period than those who have migraine without aura.  The converse of this is that practices that specialize in vertigo find 16-32% of their patients have migraine.

 Definition of entities.

Migraine without aura

Previously used term—common migraine.  This is defined by the International Classification of Headache Disorders III (ICHDIII) as:

A. At least 5 attacks fulfilling criteria below:

B. Headache attacks last 4-72 hours (treated or untreated)

C. Headache has at least 2 of the following 4 characteristics:

Unilateral, one sided, hemicrania, half of head

Throbbing, pulsating quality

Moderate or severe pain intensity

Aggravation by or causing avoidance of routine physical activity

D. During headache at least one of the following:

Nausea and/or vomiting

Photophobia and phonophobia.

Migraine with aura

Previously used terms: Classic or classical migraine; ophthalmic, hemiparaesthetic, hemiplegic or aphasic migraine; migraine accompagne´ e; complicated migraine.

Description: Recurrent attacks, lasting minutes, of unilateral fully reversible visual, sensory or other central nervous system symptoms that usually develop gradually and are usually followed by headache and associated Diagnostic criteria:

A. At least two attacks fulfilling criteria B and C.

B. One or more of the following fully reversible aura symptoms: 1. visual 2. sensory 3. speech and/or language 4. motor 5. brainstem 6. Retinal.

C. At least three of the following six characteristics:

1. at least one aura symptom spreads gradually over 5 minutes

2.two or more aura symptoms occur in succession

3. each individual aura symptom lasts 5–60 minutes

4. at least one aura symptom is unilateral

5. at least one aura symptom is positive

6. the aura is accompanied, or followed within 60 minutes, by headache

D. Not better accounted for by another ICHD-3 diagnosis.

1. When, for example, three symptoms occur during an aura, the acceptable maximal duration is 60 minutes. Motor symptoms may last up to 72 hours.

2. Aphasia is always regarded as a unilateral symptom; dysarthria may or may not be.

3. Scintillations and pins and needles are positive symptoms of aura.

 Vestibular Migraine according to ICHDIII is defined as:

A. At least five episodes filling criteria (C) and (D)

B. Current or past history of migraine, either with or without aura, considering the International Classification of Headache Disorders (ICHD) criteria

C. Moderate or severe vestibular symptoms, lasting 5 minutes to 72 hours.

D. At least half of the episodes are associated with at least one of these migrainous features:

Headache with at least two of the following characteristics:

Unilateral location

Pulsating quality

Moderate or severe intensity

Aggravation by routine physical activity

Photophobia and phonophobia

Visual aura

No other better diagnostic explanation.

Previously used terms: Migraine-associated vertigo/ dizziness; migraine-related vestibulopathy; migrainous vertigo.

Meniere’s Disease signs and symptoms include:

A. Episodic rotational vertigo.  Attacks of off balance due to a spinning sensation, often accompanied by nausea and vomiting.

B. Tinnitus, which is a roaring, hissing, ringing sound in one ear.

C. Hearing Loss which may be intermittent early in the course of the disease, but usually over time causes a permanent hearing loss.

D. Ear fullness, which may come before the start of an attack.  (aural fullness).

Vestibular symptoms, as defined by the Ba´ra´ny Society’s International Classification of Vestibular ICHD-3  International Headache Society 2018 Disorders and qualifying for a diagnosis of A1.6.6 Vestibular migraine, include:

 a) spontaneous vertigo:  internal vertigo (a false sensation of self-motion)  external vertigo (a false sensation that the visual surround is spinning or flowing)

b) positional vertigo, occurring after a change of head position

c) visually induced vertigo, triggered by a complex or large moving visual stimulus

d) head motion-induced vertigo, occurring during head motion

e) head motion-induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine).

 Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued.

Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur.

At the other end of the spectrum, there are patients who may take four weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.

One symptom is sufficient during a single episode. Different symptoms may occur during different episodes. Associated symptoms may occur before, during or after the vestibular symptoms.

 History and physical examinations do not suggest another vestibular disorder or such a disorder has been considered but ruled out by appropriate investigations or such a disorder is present as a comorbid condition but episodes can be clearly differentiated.

Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks. Comments: A surprisingly high prevalence of A1.6.6 Vestibular migraine of 10.3% was recently described among migraine patients in Chinese neurological departments.

Other symptoms Transient auditory symptoms, nausea, vomiting, prostration and susceptibility to motion sickness may be associated with A1.6.6 Vestibular migraine. However, since they also occur with various other vestibular disorders, they are not included as diagnostic criteria. Relation to migraine aura and migraine with brainstem aura.

Both migraine aura and migraine with brainstem aura (formerly: basilar-type migraine) are terms defined by ICHD-3. Only a minority of patients with A1.6.6 Vestibular migraine experience their vertigo in the time frame of 5–60 minutes as defined for an aura symptom. Even fewer have their vertigo immediately before headache starts, as required for 1.2.1.1 Typical aura with headache. Therefore, episodes of A1.6.6 Vestibular migraine cannot be regarded as migraine auras. Although vertigo is reported by more than 60% of patients with 1.2.2 Migraine with brainstem aura, ICHD-3 requires at least two brainstem symptoms in addition to visual, sensory or dysphasic aura symptoms for this diagnosis. Fewer than 10% of patients with A1.6.6 Vestibular migraine fulfil these criteria.

Therefore, A1.6.6 Vestibular migraine and 1.2.2 Migraine with brainstem aura are not synonymous, although individual patients may meet the diagnostic criteria for both disorders. Relation to benign paroxysmal vertigo While A1.6.6 Vestibular migraine may start at any age, ICHD-3 specifically recognizes a childhood disorder,

Is There A Link Between Vestibular Migraine And Meniere’s Disease?  From the so-called “Headache Bible for the World”, the answer is yes, a long and time-honored link dating back to Meniere’ himself.

The 2018 International Classification of Headache Disorders III states:

Overlap with Menie`re’s disease. Migraine is more common in patients with Menie`re’s disease than in healthy controls. Many patients with features of both Menie`re’s disease and A1.6.6 Vestibular migraine have been reported. In fact, migraine and Menie`re’s disease can be inherited as a symptom cluster. Fluctuating hearing loss, tinnitus and aural pressure may occur in A1.6.6 Vestibular migraine, but hearing loss does not progress to profound levels.

Similarly, migraine headaches, photophobia, and even migraine auras are common during Menie`re attacks. The pathophysiological relationship between A1.6.6 Vestibular migraine and Menie`re’s disease remains uncertain. In the first year after onset of symptoms, differentiation between them may be challenging, since Menie`re’s disease can be monosymptomatic with only vestibular symptoms in the early stages of the disease.

When the criteria for Menie`re’s disease are met, particularly hearing loss as documented by audiometry, Menie`re’s disease should be diagnosed, even when migraine symptoms occur during the vestibular attacks. Only patients who have two different types of attacks, one fulfilling the criteria for A1.6.6 Vestibular migraine and the other for Menie`re’s disease, should be diagnosed with both disorders. A future revision of ICHD may include a vestibular migraine/Menie`re’s disease overlap syndrome.

The Book

The Book

 Related questions.

1.Does Vestibular migraine have hearing loss, ear fullness, or tinnitus?  Not usually, those are specific Meniere type symptoms which are lacking in migraine and vestibular migraine.

2.How are these 2 neurological problems diagnosed?  The diagnosis is usually through a history and neurological and otological exam.  MRI scans of migraine may show T2 microvascular disease in 30-40 % of patients, but as far as is currently known they don’t mean anything.  MRI scan for Meniere’s patients should be normal.  MRI scan could also show a tumor on the eighth (hearing/balance) nerve.  These tumors are usually benign and present with deafness, but not usually vertigo.

For migraine the neurologic exam should be normal.  For Meniere’s disease there may be deafness in one ear and gait ataxia, nystagmus,  or off balance if the patient is in the middle of an attack.

Audiogram with Meniere’s disease shows a low frequency hearing loss problem.  Audiogram is normal for migraine.

 3.What did Prosper Meniere think about this?

Prosper Menière (18 June 1799 – 7 February 1862) was a French doctor who first identified that the inner ear could be the source of a condition combining vertigo, hearing loss and tinnitus, which is now known as Ménière's disease.  He thought there was a link between the condition he described and migraine.

Meniere.jpg

 4. What causes Meniere's disease?

The cause is unknown but one theory is that it comes from an abnormality in the way fluid of the inner ear is regulated.  Meniere's disease is also called idiopathic endolymphatic hydrops.

Endolymphatic hydrops is a disorder of the vestibular system in the inner ear. It is thought to stem from abnormal fluctuations in the fluid called endolymph which fills the hearing and balance structures of the inner ear. This condition results in a distended endolymphatic space and is referred to as endolymphatic hydrops.  This condition causes visible neuropathologic changes in the inner ear.  

Usually only one ear is involved, but both ears may be affected in about 15% of patients.

Meniere's disease typically starts between the ages of 20-50 years of age (although it has been reported in nearly all age groups) and affects both sexes equally. The symptoms may be only a minor nuisance, or with time and repeat attacks, disabling.

 4. What is the treatment for Vestibular Migraine?

Just like any other migraine patient, persons with vestibular migraine should live a migraine lifestyle of regular exercise, sleep, and meals.  Their sleep/wake schedule should be standardized.  They should avoid overtreating with caffeine, Tylenol, NSAIDS, and triptans, and in general never take butalbital or opioid narcotics for headache.  They should limit all headache medicine to no more than 2 days/week.

Vestibular migraine responds to the older oral preventive drugs, like topiramate, propranolol, and amitriptyline and treating with these will decrease the number of attacks.

Whether it will respond to the new migraine CGRP preventive drugs such as Aimovig, Ajovy, and Emgality is unknown. Vestibular migraine will also respond to triptans, especially if headache comes with the vertigo attack.

 5. What is the treatment for Meniere’s disease?

The worst symptom of an attack of Meniere’s disease is the vertigo.  Anti-vertigo medication such as meclizine, Transderm scop patches, glycopyrrolate, and diuretics help relieve dizziness related vertigo and shorten the attack.  Some patients respond to the benzodiazepine drugs diazepam or lorazepam. Anti-nausea medications like Phenergan (promethazine) or Zofran (odansetron) may be given but these drugs may cause drowsiness.

Meniere’s disease causes endolymphatic hydrops, which means swelling and fluid retention in the semicircular canals  Limiting dietary salt and taking diuretics (water pills) such as  Dyazide or Lasix help some people control dizziness by reducing the amount of fluid the body retains, which may help lower fluid volume and pressure in the inner ear.

There are claims that caffeine, chocolate, and alcohol aggravate vestibular migraine symptoms, so some patients avoid or limit taking them. Not smoking also may help lessen the symptoms.

Cognitive behavioral therapy, CBT, is a skill that helps people focus on how they interpret and react to life experiences. Some people find that cognitive therapy helps them cope better with the unexpected nature of attacks and reduces their anxiety about future attacks.

Injections.  The antibiotic gentamicin can be injected into the middle ear to treat vertigo, but it may cause hearing loss because gentamicin can damage the microscopic hair cells in the inner ear.  Cortisone may be injected, which often helps reduce dizziness but has no risk of hearing loss.

Vestibular Rehabilitation.  This program includes exercises for coordinating eye and head movements and stimulating the symptoms of dizziness in order to desensitize the vestibular

System.  They help with balance and walking ability and improve fitness and endurance.

Surgery.  Rare cases of severe Meniere’s disease with disabling vertigo not responding to medication may be treated with surgical procedures:  endolymphatic shunting to drain fluid from the ear, vestibular neurectomy, labyrinthectomy (surgical removal of the labyrinth of the ear) and eighth nerve section.  Neurectomy , labyrinthectomy, and transection of the eight nerve all result in permanent deafness, but may help the vertigo.

 6. How long has there been a known relationship of migraine and vertigo?

When I was a medical student in the late 60’s Merritt’s Textbook of Neurology described migraine as being found with vertigo.  Through the years I see several articles a year in the neurology literature describing attacks of vertigo relating to migraine and I have seen many patients myself.  The Second International Classification of Headache described vertigo and migraine but didn’t use the term “vestibular migraine” but the latest, Third edition does.

Finally, vestibular migraine (VM) was integrated as an independent entity in the appendix of the International Classification of Headache Disorders 3-beta (ICHD-3 beta, A1.6.5).  This designation and definition criteria resulted from a consensus document published by the International Headache Society (IHS) and the Bárány Society (International Society for Neurootology).  It represented a collaboration between neurologists and otorhinolaryngologists.

The book to study for neurology boards. 1974

The book to study for neurology boards. 1974

 7.Relationship between migraine and Meniere’s disease.

Migraine is a genetically inherited medical problem consisting of one-sided pounding severe headache pain associated with nausea, vomiting, sensitivity to light and sound, and disability.  Migraine is defined by the International Classification of Headache as lasting 4-72 hours.  Meniere’s syndrome is an episodic disorder consisting of attacks of vertigo, sounds in the ear (tinnitus), ear fullness, and nerve deafness. 

The migraine process through the release of the inflammatory neurochemicals, Neurokinan A, Substance P, and CGRP causes neurogenic inflammation of all the sense organs—the olfactory nerve (smell-osmophobia), the retina and the optic nerve (photophobia), the eighth nerve carrying sound and balance (sonophobia, vertigo).  It is through these anatomical structures and altered neurochemicals due to migraine that migraine links to Meniere’s syndrome.

 8.  What is the literature of vestibular migraine? 

Despite the well-known relationship between migraine and vertigo in children the association between vestibular symptoms and migraine in adults was firstly recognized in 1984. In 1961, Bickerstaff in 1961 article on “Basilary Artery Migraine” made the first description of migraine with brainstem symptoms, including vertigo.  He described two patients with identical symptoms, suggesting an abnormality in basilar artery circulation. He referred that the earliest recorded description of basilar artery migraine was made by Aretaeus of Cappadocia in 131 BC.   More recently, in the ICHD-3 classification (2018), it became known as migraine with brainstem aura.

Fenichel writing in the Journal of Pediatrics in 1967 reported 2 siblings who suffered over several years from brief attacks of nausea and vertigo lasting from seconds to minutes.  Later these children developed migraine with aura.  Fenichel stated:

The proband of this report first presented at age two with symptoms of “benign paroxysmal vertigo.”  The attacks insidiously changed in character from isolated vertigo to fairly typical migraine.  Symptoms of benign paroxysmal vertigo developed in a younger brother who is now two years old.  Family history reveals a high incidence for migraine in the maternal line.

 In 1979 Slater writing in Journal of Neurology, Neurosurgery, and Psychiatry introduced a term, “Benign Recurrent Vertigo” which consisted of episodic attacks of vertigo, no cochlear symptoms, a history of migraine, and nystagmus.  Stress, lack of sleep, alcohol use, and a strong family history were also found with this group which Slater considered a migraine variant.  In 1980 Koehler presented eight young children with benign paroxysmal vertigo, a symptom complex comprised of attacks of vertigo, nystagmus, and ataxia.  Follow-up studies revealed a close relationship to autonomic nervous system instability, particularly to migraine.  Moretti, at al, reported five more cases of benign paroxysmal vertigo in 1980 stressing the connection of benign recurrent vertigo to migraine.  They also commented on its prevalence in women, occurrence during menstruation, but felt that there was “no time relationship between vertigo and migraine attacks.”

Kuritzky, et al, reported in 1981 on “Vertigo, Motion Sickness and Migraine.” 

They found that patients with classical migraine (ICH--migraine with aura):

reported significantly more vestibular symptoms than controls.  Specifically, they had more dizzy spells and vertigo episodes not associated with the headache.  They also had more frequent motion sickness spells.

 Kayan and Hood writing in Brain in 1984 on “Neuro-otological manifestations of migraine” studied vestibulocochlear derangements in 3 groups of patients:  200 migraine patients, 80 migrainous patients referred for neuro-otological examination because of their symptoms, and 116 tension headache patients who served as controls.

Significant differences were established among these groups.  Migraine patients had vestibulococlear disturbances as an aura, during headache-free times, or, with highest incidence, during the headache.  Fifty-nine percent of the 200 migraine patients reported vestibular and/or cochlear symptoms which were disabling for 5%.  Also 50% of the migraine patients had a history of motion sickness and 81% developed phonophobia during the headache.

Persisting vestibulocochlear derangements were found in 77.5% of the 80 patients referred for neuro-otological examination.  Kayan and Hood discussed “possible links between Meniere’s disease, benign paroxysmal vertigo, and migraine.”

In 1995 Abu-Arafeh and Russell wrote in Cephalalgia on “Paroxysmal vertigo as a migraine equivalent in children: a population study.”  They studied the prevalence, causes, and clinical features of paroxysmal vertigo (PV) in the City of Aberdeen in 2165 children utilizing a screening questionnaire.  Children with a history of 3 episodes of vertigo were invited for clinical interview and exam.  Forty-five children fulfilled the criteria for PV (prevalence rate 2.6%).  These children were noted to have features common to children with migraine along with abdominal pain, cyclical vomiting, atopy, and motion sickness.  These children had a two-fold increase in the prevalence of migraine (24%) compared with the general childhood population.  The authors concluded that migraine and PV were related and that it was “reasonable to continue to regard PV as a migraine equivalent."

Buchholz and Reich writing in 1996 in Seminars in Neurology on “The menagerie of migraine” reported that migraine may have hearing loss and vestibular dysfunction.  Lindskog in 1999 writing in 1999 in Headache on “Benign Paroxysmal Vertigo in Childhood:  A Long-Term Follow-up” found no relationship between childhood Benign Positional Vertigo (BPV) and migraine in a long term follow-up.  These researchers followed 19 children aged 5 months to 8 years diagnosed in 1975-1981 with BPV.  Follow-up was performed 13-20 years after diagnosis and 21% developed migraine which is more than expected in a normal population of that age.  None of the patients had trouble with balance or vertigo at follow-up.  The authors concluded that BPV has a good outcome and is “not a general precursor of migraine.”  However, most of the published articles on the subject do not agree.

Baloh writing in 1997 in Headache on “Neurotology of Migraine” stated that “Neurotology symptoms are common with migraine, yet relatively little is known about the pathophysiology of such symptoms.”  Baloh found motion sensitivity with motion sickness in 2/3 and vertigo in 1/4 of patients with migraine.  He thought that sensitivity to sound (phonophobia) was the most common migraine auditory symptom but fluctuating and permanent hearing loss may rarely occur.  Baloh noted that migraine can imitate Meniere’s disease and that so-called “vestibular Meniere’s disease” is usually associated with migraine.

Dieterich and Brandt writing in 1999 in Journal of Neurology on “Episodic vertigo related to migraine (90 cases):  vestibular migraine?” performed a retrospective study on 90 patients with episodic vertigo that could be related to migraine but that did not fulfill IHS criteria for basilar migraine.  The following features were noted:

Occurrence was anytime in life with a peak in the 4th decade in men and a plateau between the 3rd and 5th decade in women; duration of rotational (78%) and/or to-and fro vertigo (38%) lasting from seconds to several hours, or less frequently even days.  Monosymptomatic audiovestibular attacks (78%) occurred as vertigo associated with auditory symptoms in only 16%.  Vertigo was not associated with headache in 32% of the patients.  In the symptom-free interval 66% of the patients showed mild central ocular motor signs such as vertical (48%) and/or horizontal (22%) saccadic pursuit, gaze-evoked nystagmus (27%), moderate positional nystagmus (11%), and spontaneous nystagmus (11%).  Combinations with other forms of migraine were found in 52%.

 Dieterich and Brandt stated. “migraine is a relevant differential diagnosis for episodic vertigo.”  They proposed using the more appropriate term “vestibular migraine.”

Radtke, et al, writing in Neurology in 2002 on “Migraine and Meniere’s disease:  is there a link?” commented that Prosper Meniere had suggested a relationship between the two episodic clinical syndromes in Paris in 1861 when he discussed the illness that bears his name.  Radtke, et al, determined the lifetime prevalence of migraine in patients with Meniere’s disease (MD) compared to sex- and age-matched controls.  They studied 78 patients with idiopathic unilateral or bilateral MD according to the criteria of the American Academy of Otolaryngology.  Migraine was diagnosed by phone interviews using ICHD criteria.

Information concerning the concurrence of vertigo and migrainous symptoms during Meniere attacks was also collected.  The lifetime prevalence of migraine with and without aura was higher in the MD group (56%) compared to controls (25%: p<0.001).  Forty-five percent of the patients with MD always experienced at least one migrainous symptom (migrainous headache, photophobia, aura symptoms) with Meniere attacks.  Radtke, et al, concluded:

The lifetime prevalence of migraine is increased in patients with MD when strict diagnostic criteria for both conditions are applied.  The frequent occurrence of migrainous symptoms during Ménière attacks suggests a pathophysiologic link between the two diseases.  Alternatively, because migraine itself is a frequent cause of audio-vestibular symptoms, current diagnostic criteria may not differentiate between MD and migrainous vertigo.

 Neuhauser and Lempert, in Germany reported in 2004 in Cephalalgia on “Vertigo and dizziness related to migraine:  a diagnostic challenge.”  These authors stated:

Migrainous vertigo (MV) is a vestibular syndrome caused by migraine and presents with attacks of spontaneous or positional vertigo lasting seconds to days and migrainous symptoms during the attack.  MV is the most common cause of spontaneous recurrent vertigo and is presently not included in the International Headache Society classification of migraine.  Benign paroxysmal positional vertigo (BPPV) and Ménière's disease (MD) are statistically related to migraine, but the possible pathogenetic links have not been established.  Moreover, migraineurs suffer from motion sickness more often than controls.

 Neuhauser, et al, writing in 2006 in Neurology on “Migrainous vertigo:  Prevalence and impact on quality of life,” studied the epidemiology of migrainous vertigo (MV) in the general population by assessing prevalence, clinical features, comorbid conditions, quality of life, and health care utilization.  They screened 4,869 adults for dizziness and vertigo and then followed up with validated neurotologic telephone interviews.  They used the diagnostic criteria for benign recurrent vertigo and migraine according to the IHS.  They reported a lifetime prevalence of MV of 0.98% and a 12-month prevalence of 0.89%.  Spontaneous rotational vertigo was reported by 67% of patients with MV while 24% had positional vertigo.  Twenty-four percent always experienced headaches with their vertigo.  Neuhauser, et al, concluded:

Migrainous vertigo is relatively common but under diagnosed in the general population and has considerable personal and healthcare impact.

 9.What is the incidence of migraine and vertigo?

Migraine causes more vertigo than any other condition.  The incidence of migraine in the United States is 12% while the incidence of Meniere’s disease is 0.2%.  About 50% of patients with Meniere’s disease have migraine.  Neurologic practices focusing on headache report episodic vertigo in 27-42% of migraineurs.  Dizziness, vertigo, tinnitus, photophobia, hearing loss, and nystagmus may accompany migraine.  Migrainous vertigo may occur without headache.  Typical acute and preventive treatment for migraine may improve migrainous vertigo.

10.What is the differential diagnosis of migrainous vertigo?

This includes ear infection, brain stem infarct, autoimmune inner ear disease, multiple sclerosis, early Meniere’s disease, vertebrobasilar ischemia, cerebellar tumor, and Arnold-Chiari malformation.

11.What is Benign Paroxysmal Vertigo?

ICHD III describes it as: “A disorder characterized by recurrent brief attacks of vertigo, occurring without warning and resolving spontaneously, in otherwise healthy children.”

Diagnostic criteria:

A. At least five attacks fulfilling criteria B and C.

B. Vertigo occurring without warning, maximal at onset and resolving spontaneously after minutes to hours without loss of consciousness.

C. At least one of the following five associated symptoms or signs:

1. nystagmus

2. ataxia

3. vomiting

4. pallor

5. fearfulness

D. Normal neurological examination and audiometric and vestibular functions between attacks

E. Not attributed to another disorder.2

 Notes:

1. Young children with vertigo may not be able to describe vertiginous symptoms. Parental observation of episodic periods of unsteadiness may be interpreted as vertigo in young children.

2. In particular, posterior fossa tumors, seizures and vestibular disorders have been excluded.

Comment: The relationship between 1.6.2 Benign paroxysmal vertigo and A1.6.6 Vestibular migraine (see Appendix) needs to be further examined.

Summary:

Migraine with vertigo is common. Vestibular migraine relates to Meniere’s Disease.  The clinical diagnosis is made by history and neurologic exam.  If tinnitus, deafness, or hearing loss occur, migraine with Meniere’s Disease should be considered.  An attack lasting more than 3 days should be worked up with CT or MRI scanning and otolaryngologist evaluation and audiogram.

Treatment would be as for migraine—acute treatment for headache with a triptan, and the usual migraine preventive drugs.  Anti-vertigo, Anti-nausea, and diuretics may help.  The incidence of Meniere’s Disease is very rare.

Good luck with this.

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Britt Talley Daniel MD