“If I have a patient with vertigo and we’re not getting control easily, I may treat for migraine to see if it works.”Explore This Issue
June 2011—Carol Foster, MD
Overdiagnosis?
The lingering uncertainty over diagnosis and treatment has led some critics to openly question whether the condition is being oversold. Neurotologists at the University of British Columbia recently published a commentary in the journal Headache in which they labeled migraine-associated vertigo as “neither clinically nor biologically plausible as a migraine variant” (2010;50(8):1362-1365).
Among otolaryngologists, however, that sentiment appears to be a minority viewpoint. “I think the diagnosis of migraine-associated vertigo is more widely received now than it had been previously,” said Joe Walter Kutz, MD, assistant professor of otolaryngology at the University of Texas Southwestern Medical Center in Dallas. “It’s still a difficult diagnosis to make, and there is still controversy.”
The International Headache Society (IHS) does not yet recognize migraine-associated vertigo as a distinct entity, although several movements are afoot to establish more formal diagnostic criteria, including one led by Hannelore Neuhauser, MD, MPH, of the department of epidemiology and health reporting at the Robert Koch Institute in Berlin.
With a lack of agreed-upon guidelines, other efforts are underway to compile data that might better delineate the condition. One example is the CHEER Network (Creating Healthcare Excellence through Education and Research), which is building a national infrastructure for practice-based clinical research focused on hearing and balance disorders. According to network co-principal investigator Debara Tucci, MD, professor of otolaryngology-head and neck surgery at Duke University Medical Center in Durham, N.C., a team led by investigators at the University of California-Los Angeles and Mayo Clinic in Rochester, Minn., is seeking funding for a proposal to further define migraine-associated vertigo. The epidemiological research, she said, would tap into the CHEER Network.
Evidence that clinicians are expanding on the traditional view of what constitutes a migraine comes from a recent Otology & Neurotology study of 26 patients who had experienced at least three months of otalgia symptoms of unclear origin (2011;32(2):322-325). Only 17 of the patients fit the IHS criteria for a migraine. Nevertheless, 24 responded well to migraine preventive and abortive therapies, based on a scored comparison of pre- and post-treatment symptom severity, frequency and duration. Dr. Foster agreed that restricting treatment to those with classic IHS migraine could leave out a host of patients who might otherwise benefit. “The reality is that if I have a patient with vertigo, especially a damaging vertigo, and we’re not getting control easily, I may treat for migraine to see if it works, because it’s so common,” she said.