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.

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Figure. Criteria for migraine headache include unilateral throbbing pain accompanied by nausea/vomiting, photophobia, or phonophobia.

Ménière’s Disease and Migraine-Associated Dizziness

Migraine and Ménière’s disease overlap in a small percentage of patients, said Robert A. Battista, MD, Assistant Professor of Clinical Otolaryngology at Northwestern University in Chicago. The prevalence of migraine in the United States is 3.5% and the prevalence of Ménière’s disease is 0.3%.

Ménière’s disease is characterized by more than two episodes of rotational vertigo lasting from 20 minutes to 24 hours. Ménière’s is accompanied by sensorineural hearing loss, tinnitus, or aural fullness, and other causes of hearing problems should be excluded before the diagnosis can be made.

Dr. Battista said that 10% of migraineurs have aura, and that vertigo can be an aura. Migraine aura develops over five to 20 minutes and lasts from five to 60 minutes. Up to 80% of migraine patients experience a prodrome phase prior to onset of headache pain. Manifestations of the prodrome include irritability and changes in mental status, yawning, dizziness, and nausea or vomiting.

Overlapping symptoms of migraine and Ménière’s disease include vertigo, hearing loss, tinnitus, aural fullness, and drop attacks; symptoms exclusive to migraine are photophobia, phonophobia, aura, and migraine headache. If patients have any of the migraine symptoms and are dizzy, think migrainous vertigo, Dr. Battista told the audience.

Migraine-associated dizziness is accompanied by vertigo in 50% of cases, and more than 25% of the time the vertigo lasts more than 24 hours; by contrast, episodes of Ménière’s dizziness are shorter. In addition to vertigo, patients with migraine-associated dizziness may experience nonvertiginous dizziness, such as lightheadedness and disequilibrium. Hearing loss in migraine-associated dizziness is not progressive, but it is with Ménière’s disease.

Medical Therapy for Migraine-Associated Dizziness

Patients with migraine-associated dizziness are frequently bounced around from doctor to doctor because they are often misdiagnosed, said Joel A. Goebel, MD, Professor and Vice-Chair of the Department of Otolaryngology-Head and Neck Surgery at Washington University School of Medicine in St. Louis.

The million-dollar question is, ‘Are you photophobic with your dizzy spell?’, he told listeners. If the answer is yes, give the patient a migraine-elimination diet and a six-week trial of prophylactic medications.

The medications Dr. Goebel suggested are both off-label and on-label. His first choice is nortriptyline, 25 mg to 75 mg/day administered in graduated doses taken at night. Most female patients are controlled on 25 mg to 50 mg/day, and most men require 50 mg to 75 mg/day. Side effects are dry mouth, minimal weight gain, increase in blood pressure (adjust dose of nortriptyline), and palpitations. Female patients should be advised not to get pregnant if taking nortriptyline, Dr. Goebel said.

Another good choice is sustained-release verapamil 120, 180, or 250 mg/day. Other antihypertensive agents that may be helpful include propranolol, 160 mg to 240 mg/day, and atenolol, 25 mg to 50 mg/day.

If patients are hypertensive and on another antihypertensive agent, you will need to adjust medications. Be alert for low blood pressure, bradycardia, and low energy. Also, antihypertensive agents can exacerbate pre-existing depression, he said.

Topiramate, 50 mg twice a day in graduated doses, can also be used to treat migraine-associated dizziness. Side effects include paresthesias, nausea, fatigue, inattention, and weight loss.

If these medications are not effective, Dr. Goebel refers the patient to a neurologist. He emphasized that the triptans can abort acute migraine headache but are ineffective for migraine-associated dizziness.

Vestibular Rehabilitation for Migraine-Associated Dizziness

If migraine-associated dizziness is controlled with medications, then vestibular rehabilitation can be helpful, explained Kim R. Gottshall, PhD, Director of Vestibular Evaluation and Rehabilitation at the Spatial Orientation Center at the Naval Medical Center in San Diego.

Assessment tools include the following:

• Dizziness Handicap Inventory (25 questions about emotional and functional problems)
• Activity-Specific Balance Confidence scale (questions about tasks and confidence, such as walking up stairs, standing on toes, and walking up a ramp, escalator, icy sidewalk)
• Dynamic Gait Index (assessing walking straight ahead, pivotal turn, and up and down stairs)
• Tinetti Assessment Tool (assesses fall risk in elderly patients).

Once the patient is assessed using these tools, a customized exercise program can be developed for each patient. The various types of exercise address vestibulo-ocular reflex, cervico-ocular reflex, depth perception, somatosensory retraining, gait training, aerobic activity, core stability exercises, plyometrics, and return to sports and work.

©2007 The Triological Society