Vestibular Migraine

1. VESTIBULAR MIGRAINE
Ade Wijaya, MD – May 2018

2. Outline
• Introduction
• Epidemiology
• Pathophysiology
• Diagnostic Criteria
• Clinical Presentation
• Differential Diagnosis
• Treatment
• Summary

3. Introduction
• Headache and vertigo are common
• 30-50 % simultaneous
• Link between those two first described by
Aretaeus of Cappadocia in 131 BC
• Studies since 1984
• Dieterich and Brandt were the first to use the
term ‘vestibular migraine’ (VM)
Stolte, B., Holle, D., Naegel, S., Diener, H. C., & Obermann, M. (2015). Vestibular migraine. Cephalalgia, 35(3), 262-270.
Dieterich, M., Obermann, M., & Celebisoy, N. (2016). Vestibular migraine: the most frequent entity of episodic vertigo. Journal of neurology, 263(1), 82-89.

4. Epidemiology
• 1 year prevalence: 0,9-3,2 %
• Vertigo/dizziness in 9-47,5 % patients with
migraine
• F > M (1,5-5 X)
• Can occur at any age
• Most frequent form of vertigo in children
Dieterich, M., Obermann, M., & Celebisoy, N. (2016). Vestibular migraine: the most frequent entity of episodic vertigo. Journal of neurology, 263(1), 82-89.
Stolte, B., Holle, D., Naegel, S., Diener, H. C., & Obermann, M. (2015). Vestibular migraine. Cephalalgia, 35(3), 262-270.

5. Pathophysiology
Espinosa-Sanchez, J. M., & Lopez-Escamez, J. A. (2015). New insights into pathophysiology of vestibular migraine. Frontiers in neurology, 6, 12.

6. Diagnostic Criteria
A. At least five episodes fulfilling criteria C and D
B. A current or past history of 1.1 Migraine without aura or 1.2 Migraine with aura
C. Vestibular symptoms of moderate or severe intensity, lasting between 5 minutes and 72 hours
D. At least 50% of episodes are associated with at least one of the following three migrainous features:
1. headache with at least two of the following four characteristics:
• a) unilateral location
• b) pulsating quality
• c) moderate or severe intensity
• d) aggravation by routine physical activity
2. photophobia and phonophobia
3. visual aura
E. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder.
Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, Bisdorff A, Versino M, Evers S, Newman-Toker D (2012) Vestibular migraine: diagnostic criteria. J Vest Res
22:167–172
International Headache Society Classification Subcommittee (2013) The international classification of headache disorders. 3rd edition (beta version). Cephalalgia 33:629–808

7. Clinical Presentation
Stolte, B., Holle, D., Naegel, S., Diener, H. C., & Obermann, M. (2015). Vestibular migraine. Cephalalgia, 35(3), 262-270.

8. Differential Diagnosis
• Meniere’s disease
• Somatoform vertigo (primary or secondary that
develops after vestibular vertigo)
• Benign paroxysmal positional vertigo (BPPV)
• Transient ischemia of the posterior circulation (TIA)
• Syncope and orthostatic hypotension
• Vestibular paroxymia
• Episodic ataxia type 2
• Basilar-type migraine
Stolte, B., Holle, D., Naegel, S., Diener, H. C., & Obermann, M. (2015). Vestibular migraine. Cephalalgia, 35(3), 262-270.

9. Treatment
• = migraine
• Zolmitriptan DOC for acute attack
• Migraine prophylaxis
• Vestibular rehabilitation training
Dieterich, M., Obermann, M., & Celebisoy, N. (2016). Vestibular migraine: the most frequent entity of episodic vertigo. Journal of neurology, 263(1), 82-89.
Stolte, B., Holle, D., Naegel, S., Diener, H. C., & Obermann, M. (2015). Vestibular migraine. Cephalalgia, 35(3), 262-270.

10. Summary
• Common
• Often misdiagnosis
• Clinical diagnosis
• Abortive and prophylactic treatments