2. T.Z. is 40 yrs old
gentleman
Attending the
LHC with a
complain of
rotational feeling
of the
surrounding
which is worse
for the last 2
weeks.
3. The symptoms started first 8 yrs back.
Initially he will get one episode per 2-3
months
Description of an episode: sensation of
rotational feeling of the surrounding, will
not be able to balance during walking,
sometimes has numbness of the LL.
May be associated with nausea and
vomiting
The episode may last 1-2 hrs. the patient
will sleep when the symptoms start and
feels better when he wakes up.
4. Recently the frequency of the episodes
started to increase Almost every week
Last Week the episodes of vertigo are
happening every day
And symptoms are not resolving even
after sleep.
5. Symptoms are present at rest, feeling of
imbalance during walking
No headache or visual complains
No hearing problems , no tinnitus, no ear
discharge
No h/o fever
No h/o recent viral URI
No h/o head injury
6. Past Medical History: Uremarkable apart
from episodes of vertigo
Surgical history: nil
Allergies: nil
Family history: f/h/o migrain headache in
sibling
Social History :
Married with children, working as a clerk
Non smoker or alcohol consumer
The symptoms of vertigo has significantly
affected his lifestyle, esp over the last 2
weeks
7. Patient attended
ENT clinic at
tertiary care
center and was
started on
betahistine but
no improvement
in his symptoms
8. Because his
symptoms didn’t
improve, he
attended A/E at
Royal Hospital
were CT brain
was done and it
ruled out acute
insult to the brain
9. Patient was referred from the LHC to
ENT Al-Nahdah hospital for further
evaluation.
10. ENT examination:
Otoscopy: TM clear b/l , no ear discharge
Dix Hallipike test –ve
No nystagmaus
11.
12. The patient was referred back to the
local health center, advised referral to
Khoula Hospital Neurology with
impression of …
13.
14. Vestibular migraine represents the
second most common cause of vertigo
after benign positional vertigo by far
exceeding Menière’s disease
15. The manifestations of vestibular vertigo
may include:
episodic true vertigo
positional vertigo
constant imbalance
movement-associated dysequilibrium,
and/or lightheadedness.
16. Symptoms can occur before the onset of
headache, during a headache, or during
a headache-free interval.
Many patients who
experience migraine have vertigo or
dizziness as the main symptom rather
than headache.
17. Episodic vertigo
occurs in about
25-35% of all
migraine
patients.
Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence.
A review of population-based studies.
Neurology. 1994 Jun. 44(6 Suppl 4):S17-23.
18. A Turkish study of 100 children
with vertigo who presented to a
pediatric neurology referral
center found that migraine-
associated vertigo was the fourth
most common form of the
condition (11%)
Batu ED, Anlar B, Topcu M, et al. Vertigo in childhood:
a retrospective series of 100 children.
Eur J Paediatr Neurol. 2015 Mar. 19(2):226-32.
19. The etiology of migraine-associated
vertigo is not completely understood.
Migraine headache and migraine-
associated vertigo are often triggered
by certain factors, including stress,
anxiety, hypoglycemia, fluctuating
estrogen, certain foods, and smoking.
20. Commonly accepted theory regarding
the pathophysiology of migraine-
associated vertigo
Episodes of dizziness of a duration
similar to that of a migraine aura (<
60min) that are time-locked with the
headache most likely have the same
pathophysiologic mechanism
21. According to the spreading depression theory, some
type of stimulus (eg, chemical, mechanical) results
in a transient wave front that suppresses central
neuronal activity.
This depression spreads in all directions from its
site of origin.
Neuronal depression is accompanied by large ion
fluxes, including increases in extracellular
potassium (K+) and decreases in extracellular
calcium (Ca++).
These changes result in a reduction in cerebral
blood flow in the areas of spreading depression.
22. A varied range of
dizzy symptoms even
within individual
attacks.
These symptoms may
be solitary or may be
a combination of
vertigo,
lightheadedness, and
imbalance.
A thorough headache
history is also
important
23. Dizziness symptoms present for a few
weeks or for several years.
Vertigo may occur spontaneously,
provoked by head motion or by visual
stimuli.
Symptoms may last for a few minutes or
may be continuous for several weeks or
months.
In women, dizziness may often occur
during the menstrual cycle.
24. Patients with migraine-associated
vertigo often provide a long history of
motion intolerance during car, boat, or
air travel
Vertigo is the most common type of
dizziness reported, and it is present at
some time in approximately 70% of
patients.
25. Most patients have dizziness symptoms
during headache-free intervals or even
numerous years following their last
migraine headache.
Some patients with migraine-associated
vertigo have never experienced a
migraine headache but have a family
history of migraine.
26. Findings on a complete neurologic
examination are often normal.
Horizontal rotary spontaneous
nystagmus may be present during an
acute attack of vertigo.
27. No diagnostic tests exist for migraine-
associated vertigo.
history is the most important means to
diagnose this condition.
When the history is unclear, the
diagnosis is made by a therapeutic
response to treatment.
28. Proposed criteria for the diagnosis of
probable migraine-associated vertigo include
the following:
Episodic vestibular symptoms of at least
moderate severity - Rotational vertigo, other
illusory self or object motion, positional
vertigo, head motion intolerance
At least 1 of the following:
Migraine according to the criteria of the IHS,
Migrainous symptoms during vertigo
Migraine-specific precipitants of vertigo (eg,
specific foods, sleep irregularities, hormonal
changes)
response to antimigraine drugs
Other causes ruled out by appropriate
investigations
29. Peripheral vestibular
disorders include
the following:
Ménière disease
Perilymphatic fistula
Benign paroxysmal
positional vertigo
Recurrent vestibular
neuritis
Recurrent
vestibulopathy
Central vestibular
disorders include
the following:
Multiple sclerosis
Central paroxysmal
positional vertigo
Vertebrobasilar
artery insufficiency
Cervicomedullary
compression from
abnormalities of the
craniovertebral
junction
30. Symptom
Migraine-Associated
Vertigo
Ménière Disease
Vertigo May last >24h Lasts up to 24h
Sensorineural
hearing loss
Very uncommon; when
present, often low
frequency; very rarely
progressive; may fluctuate
in cases of basilar
migraine
Nearly always
progressive; most
often unilateral; may
be bilateral; fluctuation
is common
Tinnitus
May be unilateral or
bilateral; rarely obtrusive
May be unilateral or
bilateral; often of
significant intensity
Photophobia
Often present; may or may
not be associated with
dizziness
Never present unless
a concurrent history of
migraine exists
32. The first step should always be to give the
patient a diagnosis and for the patient to
accept this diagnosis.
Rare and long vestibular spells would call for
rescue medication only / frequent and/or
short episodes would require a prophylactic
approach.
It is important to consider comorbidities,
such as arterial hypertension or hypotension,
anxiety and depression, asthma and body
weight
establish if vertigo and headaches are
equally distressing or whether one is more
pronounced than the other.
33. General recommendations for migraine
headache prophylaxis, such as diet,
sleep hygiene, avoidance of trigger
factors, are probably also beneficial for
migrainous vertigo
Biofeedback methods have been
reported for other kinds of equilibrium
problems or vertigo but to date such
studies have not been reported for
vestibular migraine
34. The duration of individual attacks of
vestibular migraine varies widely from
seconds to weeks, but mostly they last
from minutes to hours
In the case of prolonged attacks, a
symptomatic rescue treatment could be
considered.
35. Acute antivertiginous and antiemetic drugs
are considered useful for suppressing
vestibular symptoms such as
promethazine 25 or 50 mg which
combines antivertiginous, antiemetic and
sedating properties
metoclopramide which helps to control
the nausea and vomiting associated with
both headache and vertigo
Antihistaminic drugs such as
dimenhydrinate and meclizine are useful for
treating milder episodes of vertigo and for
controlling motion sickness.
National Center for Biotechnology Information, U.S. Ther Adv Neurol Disord.
2011 May; 4(3): 183–191.
Management of vestibular migraine
Alexandre R. Bisdorff
36. In a retrospective study based on
patient records, sumatriptan was found
to be efficient when the vestibular
symptoms were linked or not linked to
the headache.
If individual attacks need to be treated
it would be safer to use a generic
strategy with symptomatic drugs to
relieve vertigo and nausea, as in other
causes of acute vertigo
37. If quick relief is needed, a calcium antagonist
(flunarizine or verapamil)
in the case of prolonged treatment, watch out
for extrapyramidal side effects and depression
for flunarizine.
When there is coexisting hypertension, a
betablocker should be considered if
bronchospasm or bradycardia is not a problem.
If headaches are prominent consider the
anticonvulsant topiramate in obese patients
and valproate in nonobese patients,
38. When there is coexisting sleep disturbance
and anxiety consider amitryptiline or
nortryptiline.
If psychiatric symptoms are prominent,
benzodiazepines, SSRI and/or a referral to a
psychiatrist or behavioural therapist should be
considered.
If headache is rare compared with vertigo
and/or the vertigo is part of an aura,
lamotrigine could be given as first choice.
39. Acetazolamide is a potentially
interesting drug for vestibular migraine.
So far this drug has mainly been
observed to be highly effective for
episodic ataxia and a familial syndrome
of migraine, vertigo and tremor.
40. Referral to vestibular rehabilitation should be
considered for all patients, particularly if
secondary complications such as
deconditioning, loss of confidence in balance
or visual dependence have developed
41.
42. National Center for Biotechnology Information, U.S.
Ther Adv Neurol Disord. 2011 May; 4(3): 183–
191.Management of vestibular migraineAlexandre R.
Bisdorff
Migraine-Associated Vertigo, Mar 09, 2017 ,
Author: Aaron G Benson, MD; Chief Editor: Arlen D
Meyers, MD, MBA
