Migraine-Associated Dizziness Is Elusive to Diagnose

WASHINGTON, DC-Although migraine headache and dizziness coexist in a sizable proportion of the general population, the interface between migraine and dizziness is not well understood, according to a panel of experts. Ten percent of adults in the United States have migraine, but 30% to 40% of patients seen in dizziness clinics have migraine, and this suggests that there is more than a coincidental association of migraine and dizziness. About 10% of dizziness clinic patients have vertigo caused by migraine, and patients with migraine are more likely to suffer from Ménière’s disease and benign paroxysmal positional vertigo (BPPV), explained Stephen P. Cass, MD, Associate Professor in the Department of Otolaryngology at the University of Colorado Health Sciences Center in Denver.

There are no internationally accepted criteria for migraine-associated dizziness, he said. However, the following working criteria were proposed by Neuhauser et al. in Neurology in 2001: recurrent episodic vertigo symptoms and current or prior history of migraine; and at least one migraine symptom during two episodes of vertigo (Neuhauser H et al. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001; 56(4):436-41).

To diagnose migraine-associated dizziness, the otolaryngologist needs to know the criteria for migraine headache, which include unilateral throbbing pain lasting from four to 72 hours accompanied by nausea/vomiting, photophobia, or phonophobia. Migraine preferentially affects women of childbearing years, can be triggered by stress or red wine or fluorescent lights, and patients with migraine often need to go to bed. Vertigo occurs most often in patients who have had migraine episodes without aura, Dr. Cass said, but it can also occur in migraine with aura.

It is important to take a thorough history. Patients may or may not have a history of concurrent migraine. Dizziness can occur during a headache-free interval, or many years after the last migraine. Dizziness symptoms include spontaneous rotational vertigo, positional symptoms, motion intolerance, and visual motor sensitivity.

These symptoms can occur for seconds, minutes, or hours, Dr. Cass said.

Vestibular testing is not diagnostic, he continued. Vestibular signs can be prominent during acute migraine but are less common in between headaches. Auditory symptoms such as hearing loss, tinnitus, and ear fullness are not uncommon but are rarely as prominent as vestibular symptoms, he said. Auditory symptoms tend to be bilateral and not progressive or fluctuating.

When dizziness occurs in a patient who has migraine and there is no alternative explanation for the dizziness, Dr. Cass advised a trial of medications.