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Equilibrium March 2016 l 1

Whirled Foundation Quarterly Newsletter

March 2016 • $5Equilibrium

SPECIAL EDITION:Vestibular Migraines

Research We look at the new diagnostic criteria for Vestibular Migraine… See page 6

Feature StoryNeurophysiologist Dr. Art Mallinson explains the complexity of vestibular disorders... See below

Article of InterestSymptoms, causes and treatment of Vestibular Migraine… See page 4

Article of Interest How to treat Vestibular Migraines and which is the best option for you... See page 8

Summary of a talk given by neurophysiologist Art Mallinson, PhD, to the BADD Society at St. Paul’s Hospital, Vancouver, Canada, on November 18, 2015. Dr. Mallinson performs clinical vestibular assessments in the Neuro-Otology Unit at Vancouver General Hospital and is a clinical instructor in the Faculty of Medicine at the University of British Columbia.

Dr. Mallinson’s presentation is directed at friends and family to help them understand why those with balance and dizziness disorders can look so good when they feel so unwell.

Vestibular disorders are poorly understood and can cause frustration for patients and medical professionals alike. As W.B. Matthews, a British neurologist, said, “This frequently means that after exhaustive enquiry it will still not be entirely clear what it is that the patient feels is wrong and even less so why he feels it.”

Journey of a dizzy patient

I feel dizzy and unwell and go to see my doctor. I’ve no idea what’s wrong, but at least the doctor will tell me my ears look lovely, my hearing is good, and I probably don’t have a brain

tumour – that’s a relief!

The doctor says more information is needed. I’m referred to an ear specialist who asks even more questions and sends me to a clinic that performs special balance tests. The wait to get an appointment is long. I start to wonder if these tests will serve any purpose. Did the specialist just want to get me out of the office?

Finally I’m tested. The clinician explains how the tests work and why they’re important. Some of the tests seem strange – at one point, warm water is poured into my ears. The tester measures my eye movements a lot. The tests make me feel funny and the tester apologizes a lot.

(Continued on page 3)

“What is Wrong With You?” (You Look Fine to Me!)

2 l Equilibrium March 2016

From The EditorVestibular disorders are a major cause of feeling dizzy and off balance. It is estimated that 5% of the population will experience a vestibular disorder at some stage; that is over 1 million Australians.

Chronic imbalance is something all our members can relate to. Whether it’s Meniere’s disease, Vestibular Migraine, Benign Paroxysmal Positional Vertigo or Labyrinthitis, we are all familiar with, even if we experience it slightly differently, the vertigo that accompanies vestibular dysfunction.

That’s why at Whirled Foundation we felt it was necessary to broaden our services and support to embrace people experiencing chronic

imbalance and vertigo caused by all vestibular disorders.

Vestibular disorders occur where there is damage, either temporary or permanent, to the vestibular system which causes it to malfunction. The damage can be caused by various things including a blow to the head or ear, excess fluid build-up in the inner ear, displacement of inner ear crystals, disease or infection, complications from allergies, autoimmune disorders, ageing etc. Due to the complexity of the balance system the underlying causes of vestibular symptoms are notoriously difficult to diagnose.

So it is only fitting that we begin this edition of Equilibrium with an article that looks at the complex nature of vestibular disorders and the diagnosis process. We then point the microscope on Vestibular Migraine,

which doesn’t present as obviously as you might think. For example, the condition can cause dizziness without headaches or headaches without dizziness.

Also in this edition www.whirledfoundation.org goes live. We have launched the new Whirled Foundation website. If you haven’t already, visit the site and poke around. Once you are on the website you can log in to the members forums and your profile by entering your email address at the top of the screen and clicking on “Forgotten Password”. An email will then be sent to you to reset your password. Your feedback is both welcome and appreciated, so please let us know what you think.

Editor

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President’s Report March 2016At last our new website is live at whirledfoundation.org. I hope you enjoy exploring its many new features and lots of new information.

It has been a tremendous task for Micky Sinopoli and myself, assisted by Beatrice Tarnawski. I think if we had known how much work and time was required, we would never have started the project!

As well as providing comprehensive information on balance disorders, the website makes it easy for you to order items from the shop, update your membership details and participate in the Members Forum. We are also improving the integration of social media activities with the website. Beatrice is taking the lead in developing social media and we are attracting lots of followers.

A huge vote of thanks is also due to Vice President Oleh Butchatsky, who as Chair of the Equilibrium Editorial Panel has taken on responsibility with Micky for producing this edition.

This edition focuses on Vestibular Migraine. It is the first in a planned series of an in depth look at different causes of imbalance symptoms. Enjoy reading.

I would welcome discussions with individuals willing to contribute expertise on the Board of Whirled Foundation. It is important we renew the Board personnel and attract new candidates for positions, such as the President!

If you think you have the skills and expertise to help drive Whirled Foundation forward in its mission of raising community awareness of chronic imbalance and providing support and resources to individuals experiencing the symptoms of Vestibular Disorders please contact the office.

Finally Micky has moved to Sydney for personal reasons. We are pleased that we have been able to retain her services. This will entail Micky working from home via the internet. With the marvels of modern technology, the physical location of Micky should make little difference to the service Members receive and we welcome retention of her expertise and commitment to helping Members. This also provides the opportunity for Whirled to have an even stronger presence in Sydney where many of our members and others in our broader constituency reside.

John Cook

President.


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The test results are back. I’m told that all of the tests are normal, but I still don’t feel well. What am I going to do now? What’s going on? I’m sure the specialist will think I’m crazy. And my partner thinks I’m just lazy. But I’m not making this up!

What do we know about the balance system?

The balance system (aka vestibular system) helps us move around, stand up and keep our balance. It is a silent sensory system that is always active. The balance system collects information about our environment. We can’t feel it collecting this information—it does its job without bothering to send information to the feeling and thinking parts of the brain. It works automatically around the clock, even while we’re lying in bed at night. The balance system is different from our other sensory systems. Unlike our other senses, which can be directed, our balance system can neither be controlled consciously nor ignored. We only become aware of our balance system when we challenge it, for example by learning to ride a bike, or when there is something wrong with it. If we put extra demands on the system, we can often see how it copes with these challenges (or how it tries to cope if damage or disease has caused it to malfunction).

How does the balance system work?

A basic understanding of how the balance system works can help us understand how it can make someone feel so sick when something goes wrong. The balance system has two main jobs; they are accomplished through two different reflexes. (A reflex is a pathway that does a job without us thinking about or planning it). These reflexes are:

• The vestibulo-spinal reflex

(VSR), which works to stabilize our body. The VSR works all the time, which is a good thing considering that we only have two feet and thus are always off-balance.

• The vestibulo-ocular reflex (VOR) is an ‘eye driver’ that aims and stabilizes our eyes so that we can use our 3D vision to look at things in detail.

What happens when these reflexes are damaged?

Damage to the VOR can result in vertigo (spinning sensation) and nausea. An erroneous signal is sent to the brain, making us think we’re moving when we’re not. Problems with the VSR can cause imbalance and staggering.

Under normal circumstances, the balance system is a template against which other sensory information is processed constantly and compared. In other words, the vestibular system is the ‘boss’. We are completely unaware of this automatic process when it functions properly.

When a structure in the balance system is damaged, however, its signal is no longer reliable and it may disagree with other environmental signals. If the vestibular signal is erroneous or flawed, preference is automatically given to the visual signal. In other words, the visual signal is now the ‘boss’. This disagreement, called a ‘sensory mismatch’, can generate symptoms because environmental movement is now interpreted as self-movement.

It is important to understand that it is the sensory mismatch that induces symptoms, not the damage itself.

Navigating grocery store aisles is frequently problematic

In some patients, a slight sensory disagreement is misinterpreted and becomes the new ‘gospel’. Visual information will now give an illusion of instability or movement. Problem situations for these patients include: navigating shopping malls or grocery store aisles; watching 3D movies, passing traffic, flowing water, or windshield wipers; seeing sunlight flicker through trees; and even simply looking at a striped shirt.

A copy of the visual vestibular mismatch (VVM) is sent to the nausea and anxiety centres of the brain. Though not well understood, the nausea symptoms of a VVM have been recognized since antiquity and were described accurately by Soranus of Ephesus (AD 98 – AD 138). He described being bothered by the spinning motion of a potter’s wheel and the flow of a river.

In the 1500s, the German-Swiss physician Paracelsus and French surgeon Ambrose Paré suggested a connection between the ear and the digestive system. In 1975, otolaryngologist Brian McCabe coined the term ‘supermarket syndrome’ after noting that his Ménière’s patients complained of nausea when looking up and down grocery store shelves.

Symptoms of a VVM include nausea, vomiting and sweating. Panic sensations and ‘situation avoidance’ behaviours may also be driven by vestibular dysfunction. Often these symptoms are minimal. They are not well understood and sometimes are incapacitating, overriding ‘traditional’ symptoms of spinning and imbalance. The appearance of this set of symptoms is an indirect result of (Continued on page 5)

“What is Wrong With you?” (You Look Fine to Me) (from page 1)


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Vestibular migraine is vertigo (spinning sensation) that is caused as a result of migraines. It differs from general migraine as the main feature is dizziness as opposed to headache. It affects more than 1% of the entire population and accounts for about 10% of patients who report having dizziness. Vertigo attacks that occur as a result of vestibular migraines can last from seconds to days.

Causes of Vestibular Migraine

The cause of vestibular migraine is not completely understood and it is believed to be a disorder that can be inherited. It has been speculated that abnormally high electrical activity in the brain stem area which overlaps with vestibular structures (which control balance and effect dizziness) may be the cause of vestibular migraine.

Symptoms of Vestibular Migraine

Common symptoms of vestibular migraine include vertigo, dizziness, unsteadiness and imbalance. Nausea and vomiting may occur as a result of vertigo. In addition, some sufferers can find head movements (turning or bending up or down) agonizing. Pressure may be felt in the head and/or ear. Sufferers may find hearing low pitched noises painful, experience neck pain, or experience tinnitus (ringing of the ear). People may also experience vision impairments such as blurred, blotchy or partial loss of vision.

Diagnosis of Vestibular Migraine

Criteria for the diagnosis of vestibular migraine have been developed as a guide. The four main criteria include:

• Atleast5episodesofsymptomsof moderate intensity, lasting any time between 5 minutes and 72 hours.

• Historyofexperiencingmigraines,vestibular or otherwise.

• Oneormoremigraineswhichincludes at least two of these characteristics: one sided location, pulsating quality, moderate or severe pain intensity, aggravation by routine physical activity, light and/or sound sensitivity.

• Cannotbebetterexplainedbyany other migraine or vestibular diagnosis

Treatment of Vestibular Migraine

Treatment options include lifestyle changes, medication to relieve symptoms of vestibular migraine and medications to prevent the occurrence of vestibular migraine. Lifestyle changes may be recommended to reduce the incidence of vestibular migraine triggers. Some triggers include alcohol, stress and lack of sleep. Some recommended lifestyle changes include;

• Reducingfoodanddrinkwhichact as triggers (such as alcohol or caffeine)

• Maintainingadequatewaterconsumption

• Consistentandadequatesleep

• Regularexercise

• Stressmanagement

Patients who receive preventative medications to avoid vestibular migraine are those who suffer from vestibular migraine more frequently. If you are taking preventative medication, you may be required to continuously take your medicine, even on days when you are not feeling unwell.

Prescriptions that relieve symptoms of vestibular migraines include anti-nausea medication and pain relief medication. These medications may be

used to relieve vestibular migraines as they occur.

Vestibular rehabilitation has been known to improve movement related symptoms that are experienced as a result of vestibular migraine. It may improve symptoms such as dizziness, vertigo and unsteadiness. If symptoms are triggered by movement or position changes, you may benefit from vestibular rehabilitation. If you believe this may benefit you, your doctor can refer you to a physiotherapist for an initial assessment. Vestibular rehabilitation involves an exercise regime that does not exacerbate the symptoms. As the patient tolerance to these exercises adjusts, the intensity of the exercises increases.

References:

Bisdorff AR. Management of vestibular migraine. Therapeutic advances in neurological disorders. 2011 Mar 11:1756285611401647.

John Hopkins Medicine, Vestibular Migraine [Internet] (United States), John Hopkins University, John Hopkins Hospital, John Hopkins Health System; [cited 10 Jan 2016]. Available from: http://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/vestibular/conditions/vestibular_migraine.html

Lempert T, Neuhauser H. Epidemiology of vertigo, migraine and vestibular migraine. Journal of neurology. 2009 Mar 1;256(3):333-8.

Lempert T, Olesen J, Furman J, Waterston J, Seemungal B, Carey J, Bisdorff A, Versino M, Evers S, Newman-Toker D. Vestibular migraine: diagnostic criteria. Journal of Vestibular Research. 2012 Jan 1;22(4):167.

Scientific American, What are Vestibular Migraines? [Internet] (United States), Scientific American, A Division of Nature America, INC; 2016 [cited 10 Jan 2016]. Available from: http://www.scientificamerican.com/article/what-are-vestibular-migraines/

The Royal Victorian Eye and Ear Hospital, Vestibular Migraine [Internet] Melbourne, VIC (Australia), The Royal Victorian Eye and Ear Hospital; 2014 [cited 10 Jan 2016]. Available from:http://www.eyeandear.org.au/page/Patients/Patient_information/Balance_Disorders/What_are_some_types_of_balance_disorders/Vestibular_migraine/

Vestibular Migraine: What is it?


Rec

ipe

Ingredients- 2 tablespoons olive oil

- 1 Spanish red onion, finely diced

- 50g finely grated ginger

- 2 long red chillies, finely chopped

- 2 garlic cloves, finely chopped

- 2 teaspoons brown mustard seeds

- 2.8kg ripe tomatoes

- 250ml tomato passata

- 80ml apple cider vinegar

- 55g caster sugar

MethodHeat oil in a large saucepan over medium- high heat, add onion, ginger, chilli and garlic. Cook, stirring occasionally for 4-5 minutes until tender, translucent and fragrant. Stir in mustard seeds and cook for 30-40 seconds until the seeds begin to pop.

Stir in the chopped tomatoes and passata and bring to a simmer, reduce heat to medium and simmer, stirring occasionally for 10-15 minutes until tomatoes break down. Season with fresh ground pepper and stir in vinegar and sugar. Simmer for 10-15 minutes until thick and rich.

Pulse with a hand-held blender or in a food processor to a sauce consistency. Transfer to sterilised glass jars or bottles, seal and cool to room temperature. Chutney will keep for up to 2 months in the fridge.

Printed with Permission

Queensland Hypertension AssociationBP Monitor – February 2016 Newsletter Volume 30, Number 1Salt Skip News No 197, February 2016, Page 4

damage to the balance organ. There are no good tests to detect VVM. Patients must describe their symptoms. To the clinician, this symptom set is helpful in diagnosis and must not be dismissed.

The VVM set of symptoms is real and legitimate. The bizarre symptoms can be distressing and upsetting. They do not represent psychiatric disease. They can result in ‘dizziness related depression’.

Dealing with VVM

Once the symptoms have been treated and central disease has been ruled out, what can be done for someone with VVM? In many instances, diagnosis itself can be therapeutic. Family and friends can support those with VVM by:

• understandingandacknowledgingthat the problem is real – your loved one isn’t crazy or just lazy;

• helpingreduceanxiety-thinkingabout VVM can make it worse;

• encouragingactivity–doingnothing makes VVM worse; and

• offeringongoingsupport–maintaining social connections is helpful.

View This Talk Online

Dr. Mallinson’s talk was videotaped and can be viewed on the BADD website http://balanceanddizziness.org/ from the Past Meetings page.

Sourced From “The Balance Sheet”, Quarterly Newsletter of the British Columbia Balance and Dizziness Disorders Society (BADD), Winter 2016.

Tomato, Ginger and Chilli

Chutney

“What is Wrong With you?” (You Look Fine to Me) (from page 3)


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Vestibular migraine goes by many names: migraine-associated vertigo, migraine-related vestibulopathy, and migrainous vertigo, just to name a few. The condition, which accounts for about 3% of migraines, was finally given a separate set of diagnostic criteria in the 2013 update to the International Classification of Headache Disorders, 3rd Edition. Likely underdiagnosed, vestibular migraine is often mistaken for a host of other syndromes and conditions.1

“Vestibular migraine is a mouthful of a topic. The more you look at it, the more complicated it gets. It may be the most common cause of chronic dizziness. The new diagnostic criteria will help but may be too restrictive to capture all migraineurs with vertigo,” said Jason D. Rosenberg, MD, assistant professor of neurology and director of the Johns Hopkins Headache Center.

Diagnosing Vestibular Migraine

According to the new criteria, a patient should have a history of migraine and at least five episodes of vertigo lasting between five minutes and 72 hours in order to earn a vestibular migraine diagnosis. At least 50% of these episodes should be associated with migraine-type headache, photophobia or phonophobia, or a visual aura. Vertigo of vestibular migraine may occur during or between headaches and be associated with non-headache migraine symptoms. Other vestibular disorders should also be ruled out.1

“The new criteria are useful, but many patients will fall outside of the criteria. There are no tests that rule in the diagnosis. It is almost entirely clinical,” said Jonathan H. Smith, MD, assistant professor of neurology at the University of Kentucky College of Medicine.

“Primary care doctors can make this diagnosis by ruling in migraine and ruling out peripheral causes of vertigo, like benign paroxysmal positional vertigo (BPPV). A lifelong tendency for motion sickness and vertigo, stimulated by a visually busy environment (like walking down a grocery store aisle) are supportive of the diagnosis. Sudden onset of persistent vertigo is a red flag and should suggest other causes. Remember that peripheral vertigo, Meniere’s disease, and stroke are more common in migraineurs,” said Rosenberg.

He noted that bedside testing can be very useful for ruling out peripheral causes of vertigo, including tests for dynamic visual acuity, the Hallpike maneuver for BPPV, and

a combination of the head impulse, nystagmus, and test of skew (HINTS) exam.

Etiology of Vestibular Migraine

The old vascular hypothesis of migraine has been replaced by theories of cortical habituation and genetically coded calcium channelopathies, among others. The etiology of vestibular migraine, however, is still unknown. They may represent brainstem aura

phenomena or cortical depression spreading to vestibular nuclei.1 “The best guess is that migraine is not one disorder. Different patients may have different biology,” said Smith.

“One way to look at etiology is that vertigo is just another part of migraine hypersensitivity, like pain and photophobia. But the short answer is we just don’t know,” said Rosenberg.

Vestibular Migraine Mimickers

“ENT doctors know that many patients with inner ear problems have headaches, and neurologists know that

Carving Out an Identity for Vestibular Migraine


many patients with migraine have inner ear problems,” said Rosenberg. Many experts think that BPPV, Meniere’s disease, migraines, and vertigo are all related conditions on the same spectrum.1

A study published in Frontiers of Neurology in 2014 looked at the overlap of Meniere’s disease and vestibular migraine, the two most common causes of spontaneous recurrent vertigo. In 268 patients with either disorder, it was found that a subset of patients with Meniere’s experienced migraine headaches, and some vestibular migraine patients complained of auditory symptoms like tinnitus and hearing loss, as seen in Meniere’s.2

“Meniere’s disease is a common confounder. An audiogram is a simple test that can be helpful. Patients with Meniere’s will usually have a unilateral, significant sensorineural hearing loss. Patients with vestibular migraine may have a milder, bilateral hearing loss,” said Smith.

In addition to otologic causes of vertigo, other disorders in the differential diagnosis include acoustic neuroma, brainstem lesions, posttraumatic headache or vertigo, and vascular abnormalities. “Throw in MS, stroke, and infection. Neurologic findings that are red flags include ataxia, skew, diplopia, cranial nerve abnormalities, visual field loss, and static imbalance,” said Rosenberg.

Potential Treatments

As you might expect in a disorder recently defined, treatment trials that specifically target vestibular migraine are scarce. A 2014 review of treatments published in Frontiers of Neurology could not find any randomized controlled trials on prophylactic treatment of vestibular migraine. Two randomized controlled trials (RCTs) provided limited evidence for treating vestibular migraines with triptans, testing rizatriptan, and zolmitriptan for acute attacks.3

A 2015 study, identified 65 patients with vestibular migraine out of 407 patients referred to an otolaryngology clinic for vertigo. A retrospective review of 407 patients referred to an otolaryngology clinic for vertigo identified 65 patients with vestibular migraine. The study, published in Otology & Neurotology, evaluated the response of the patients to prophylactic treatment with flunarizine (a calcium channel blocker) or propranolol. Response rate for both was above 60%. The authors concluded that vestibular migraine is common in vertigo patients and should not be overlooked because patients can benefit from prophylactic treatment.4

With a lack of proven guidelines, treatment for vestibular migraine is based on expert opinion and experience. Drugs used to treat acute episodes are usually the same

drugs used to treat migraine. Flunarizine, topiramate, beta blockers, and antidepressants have all been used for prevention.4

“I use triptans for acute attacks. For prevention I use trigger avoidance. Useful medications include topiramate, an SNRI, or verapamil. None is clearly better than the others. As a last resort, I may use a benzodiazepine and vestibular rehabilitation, but keep in mind that rehabilitation may make patients feel worse,” said Rosenberg.

“I treat acutely the same as for migraine. Preventive treatments are hit or miss and need to be individualized. Topiramate, lamotrigine, or a calcium channel blocker seem to work best. I also consider adding a benzodiazepine or an antidepressant because the experience of vertigo is very anxiety producing. Success rate overall is about the same for migraine, around 60%,” said Smith.

Although vestibular migraine has a new criteria for diagnosis, it is still a controversial, challenging, emerging, and underdiagnosed condition. It may be the most common cause of recurring or ongoing dizziness, and it certainly deserves more attention. Perhaps vestibular migraine will emerge as a distinct diagnosis with its own treatment guidelines, but “for now, I prefer to think of vestibular migraine as a syndrome of vertigo in people with migraine,” said Rosenberg.

If you’re a primary care provider unfamiliar with the above mentioned diagnostic tests, visit the Chicago Dizziness and Balance website to review protocols.

Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts. This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.

References

1. Swaminathan A, Smith JH. Migraine and vertigo. Curr Neurol Neurosci Rep. 2015;15(2):515.

2. Lopez-escamez JA, Dlugaiczyk J, Jacobs J, et al. Accompanying Symptoms Overlap during Attacks in Menière’s Disease and Vestibular Migraine. Front Neurol. 2014;5:265. Available here: http://journal.frontiersin.org/Journal/10.3389/fneur.2014.00265/full

3. Obermann M, Strupp M. Current treatment options in vestibular migraine. Front Neurol. 2014;5:257. Available here: http://journal.frontiersin.org/Journal/10.3389/fneur.2014.00257/full

4. Van ombergen A, Van rompaey V, Van de heyning P, Wuyts F. Vestibular migraine in an otolaryngology clinic: prevalence, associated symptoms, and prophylactic medication effectiveness. Otol Neurotol. 2015 Jan;36(1):133-8.

Reprinted with permission from Neurology Advisor; http://www.neurologyadvisor.com/headache/vestibular-migraine-diagnosis-and-treatment/article/394575/, by Chris Illiades, MD, 2015. © Haymarket Media, Inc.


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In a comprehensive 2011 article published by Sage Publications, Luxembourg-based Dr Alexandre R. Bisdorff discusses the nature of Vestibular Migraine and the various treatments that appear to have some positive impact.

Bisdorff reports that, though still subject to some debate and controversy, vestibular migraine is largely accepted in the “vestibular community” and probably represents the second most common cause of vertigo after benign positional vertigo, by far exceeding Meniere’s disease in its occurrence.

It has taken quite some time for vestibular migraine to be recognised as a specific condition and it was only in 2003 that the first operational definition of vestibular migraine was proposed.

The association of migraine and vertigo has been recognised for a long time but the nature of this relationship is uncertain in the absence of reliable biomarkers. Without exception, case-control studies have found an association between migraine, vertigo and dizziness beyond chance. Significantly more patients with migraine have vertigo compared with patients with tension-type headache and headache-free controls. In a German study the lifetime prevalence of migraine in the general population was found to be about 14% and the lifetime prevalence of vertigo 7%, resulting in a chance coincidence of 1%. The co-occurrence of vertigo and migraine, however, was found to be 3.2%.

The presentation of vestibular migraine varies. Symptoms include spontaneous and positional vertigo, head motion vertigo/dizziness and ataxia of variable duration, ranging from seconds to days. Most episodes have no temporal relationship with the headaches.

The quality of the data on vestibular migraine management is still relatively poor. Therefore, medical practitioners cannot be completely certain that the treatment they recommend is to be effective. However, knowledge is increasing every day and treatment procedures are likely to improve as more studies are undertaken.

The doctor’s first step should always be to give the patient a clear diagnosis and for the patient to accept this diagnosis. Although the condition can have a considerable psycho-social impact, it is medically benign and some patients are happy to receive an explanation for their symptoms and do not ask for treatment. However, treatment is often required and the choice of drugs is mainly guided by the frequency of the attacks and the side effect profile.

Rare and long vestibular spells would call for rescue medication only; frequent and/or short episodes suggest a preventative/prophylactic approach. It is important to consider comorbidities, such as arterial hypertension or hypotension, anxiety and depression, asthma and body weight, and to establish if vertigo and headaches are equally distressing or whether one is more pronounced than the other. These factors will weigh on the practitioner’s assessment and medication options, which include betablockers, calcium antagonists and anticonvulsants.

Prophylactic treatment

With vestibular migraine, episodes of vertigo are often relatively short and/or frequent. Therefore treating individual episodes is often not a viable option and so prophylactic strategies should be considered.

General recommendations for migraine headache prophylaxis, such as diet, sleep hygiene, avoidance of trigger factors, are probably also beneficial for migrainous vertigo.

Vestibular rehabilitation

Physiotherapy plays an important role in the management of vestibular conditions in general. Physiotherapy is conventionally targeted at the compensation of unilateral vestibular deficits, strategies to cope with bilateral deficits, repositioning manoeuvres for benign positional vertigo, and rehabilitation of complications such as visual dependence.

For fluctuating disorders such as Meniere’s disease and vestibular migraine the value of vestibular rehabilitation is not so well proven. However some sufferers of these unpredictable disorders have reported beneficial effects from physiotherapy.

Physiotherapy seems to be particularly useful to alleviate

Vestibular Migraine Treatment Options


the associated complications of vestibular migraine such as anxiety, visual dependence or loss of confidence in the balance system.

Pharmacological prophylaxis

Prophylactic medication in migraine has an important role if attacks are frequent or insufficiently controlled by rescue medication, and seem to converge on two targets: inhibition of cortical excitation and restoring nociceptive dysmodulation. In vestibular migraine prophylactic drug treatment is considered the mainstay of medical management, although controlled studies are largely lacking. The drugs used are often those also used for the prevention of migraine headaches, such as betablockers, calcium antagonists, anticonvulsants and antidepressants.

The choice of medication should be guided by its side effect profile and the comorbidities of patients. Betablockers such as propanolol or metoprolol are preferred in patients with hypertension but in the absence of asthma. Anticonvulsants include topiramate when patients are obese, valproic acid and lamotrigine. Lamotrigine is preferred if vertigo is more frequent than headaches. Calcium antagonists include verapamil and flunarizine. If patients have anxiety, tricyclic antidepressants such as amitryptiline or nortryptiline or SSRIs and benzodiazepines such as clonazepam are recommended. Acetazolamide is effective in rare genetic disorders related to migraine-like episodic ataxia; however, its place in vestibular migraine is still to be established.

Whilst medications can be prescribed to assist in the management of vertigo and pain associated with vestibular migraine, diet and lifestyle changes can also help.

Research suggests that certain foods and/or drinks can trigger ordinary migraine. These triggers can also be the same for vestibular migraine.

The American Council for Headache Education states that:

“Triggers do not ‘cause’ migraine. Instead, they are thought to activate processes that cause migraine in people who are prone to the condition. A certain trigger will not induce a migraine in every person; and in a single migraine sufferer, a trigger may not cause a migraine every time.”

The medical debate about diet and migraine is far from settled. However some researchers have suggested a list of foods to avoid, many of them sharing common characteristics. For example, cured sandwich meats, bacon and sausages all contain synthetic food preservatives called nitrates and nitrites, which may trigger migraine. Then there’s foods that are smoked, dried, pickled, aged or fermented. These contain a naturally occurring amino acid called Tyramine. So it is recommended by some to stay away from aged or ripened cheeses, dried and or smoked meats, olives, nuts, dried fruit, beer and foods containing yeast.

Also recommended is eliminating diet soft drinks and sugar free products as they may contain aspartame (an artificial sweetener) and Asian foods prepared with soy sauce, miso or monosodium glutamate (MSG).

Caffeine is also thought to trigger migraine, so limiting

your intake of tea, coffee, cola and chocolate may also be beneficial. Conversely, those who consume excessive caffeine and then cut down suddenly, may find that the sudden withdrawal of caffeine can be a trigger.

Other foods that have potential to trigger migraine include yoghurt, sour cream, buttermilk, citrus fruits, overripe bananas, avocados and onions.

Of course not everyone will have the same triggers. Keeping a food diary and a symptom diary can help you find yours. Try eliminating one thing at a time and document any changes in symptoms.

Stress management, regular exercise and ensuring you get adequate sleep are also important in managing vestibular migraine.

References

Britta N. Smith, PT, MMSc, Controlling Migraine Associated Dizziness with Diet, American Physical Therapy Association, Section on Neurology [cited on 5th Feb 2016] Available from: http://www.neuropt.org/docs/vsig-english-pt-fact-sheets/migraine-associated-dizziness.pdf?sfvrsn=2

Grace, C. “Can Diet affect the occurrence of vestibular migraines”, Edmonton First Aid [cited on 5th Feb 2016] Available from: http://firstaidcpredmonton.ca/can-diet-affect-the-occurrence-of-vestibular-migraines/#ixzz3zG8p6GKU

Headache Australia, Migraine – ‘A common and distressing disorder’, [cited on 5th Feb 2016] Available from: http://headacheaustralia.org.au/migraine/migraine-a-common-and-distressing-disorder/

Rienecke, K., “Vestibular Migraine and Diet” Livestrong.com, [cited on 5th Feb 2016] Available from: http://www.livestrong.com/article/307997-vestibular-migraines-diet/

University Health Services, University of California, Berkeley, “Guide to Managing Migraines” 2014, [cited on 19th Feb 2016] Available from: http://www.uhs.berkeley.edu/home/healthtopics/PDF%20Handouts/Migraines.pdf

Vestibular Migraine and Diet


If you want to learn how to manage your tinnitus, this DVD is essential viewing.

Presented by Ross McKeown and produced by the Tinnitus Association of Victoria the DVD covers various techniques and strategies to successfully manage tinnitus so that it has little or no effect on your life.

The DVD was given to 4 leading experts around the world for review, here’s what they had to say:

This DVD presents a powerful first hand understanding of tinnitus. This will validate and provide reassurance to many people with tinnitus and provide a clear pathway towards successful tinnitus management.

Myriam Westcott B.Sc., Grad Dip Aud,

Audiologist, Tinnitus and Hyperacusis Therapist Melbourne, Australia.

I highly recommend this DVD as essential viewing for all people who have suffered from tinnitus.

Ross McKeown clearly describes the process by which tinnitus can become a source of distress and outlines a practical guide to the means by which we can, by challenging our fears and misconceptions, redefine tinnitus as just another background noise that we can eventually ignore without effort.

Ross Dineen, B.B.Sc. Ph.D

Clinical Audiologist, Melbourne, Australia.

Ross McKeown presents a most informative DVD about tinnitus. He provides an up to date account of

tinnitus and first class advice on how to manage it. The information is provided in a clear, supportive and reassuring way that will be of benefit both for those who are new to tinnitus and to those who have lived with it for many years.

Ross’s remarkable ability to weave personal experience with the latest scientific views is a real strength of the DVD. I will be delighted to recommend this DVD to my patients.

Laurence McKenna, B.Sc. M. Clin.Psych. Ph.D. Post Grad. Dip.

Cognitive Therapy Head of Clinical Psychology in Adult Audiology Royal Throat Nose and Ear Hospital, London

If one were to put a face on the misery of intrusive tinnitus, undoubtedly it would be the face of the androgynous creature in the 1883 masterpiece, The Scream, by Norwegian expressionist Edvard Munch.

With this DVD we now have a face to put on the mastery of intrusive tinnitus, the calm, knowledgeable, and reassuring face of Ross McKeown. And not only do we have a face, we have a pathway to get from the misery to mastery – The 4 Keys.

My congratulations to the Tinnitus Association of Victoria and to Mr. McKeown on a truly wonderful and inspiring contribution.

Stephen M. Nagler, M.D., F.A.C.S.

Atlanta, Georgia, USA

Available Now from Whirled FoundationOrder your copy online by visiting our website www.whirledfoundation.org or call 1300 368 818. $35 includes postage and handling.

The 4 Keys to Successful Tinnitus Management


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New website launched with great new features.

Our new website containing a wealth of information on balance disorders and chronic vertigo is now live.

It is designed to provide practical advice and researched information that is accurate, balanced and up to date. Our goal is both to assist individuals seeking help in living more successfully with chronic imbalance and to raise awareness of vestibular disorders in the community.

We are also seeking to build a stronger community of people who have vestibular disorders and to achieve greater public recognition and understanding of what they experience.

The new website has lots of new features including:

• morecategoriesofhelpandinformation

• an“actionplan”toguidepeopleexperiencing imbalance symptoms.

• ExpandedMembersForum

• Strongerlinkswithsocialmedia.

• Opportunitiestobeinvolved

• Personalsstoriesandtestimonies

• Videoresources

• onlineshopping.

• abilitytomanagemembershiponline

The website has taken a lot of effort and time to develop. We welcome your feedback.

Invariably errors and links failing to work properly will be discovered. Please be patient with us, as our limited financial resources means we have a very small staff. Also our volunteers are already working long hours! Please let us have your suggestions and comments.

If you find the website helpful please share it widely with your friends and within your community.

We also value any financial and volunteer support you are able to offer. This will enable us to further expand our assistance and raise awareness.

Enjoy exploring the new website!

whirledfoundation.org


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Important Notice and Disclaimer

Information in Equilibrium is not intended to be a substitute for individual professional medical advice, diagnosis, or treatment.

You should not alter, discontinue, or refrain from taking any medication, or refrain from having any other medical treatment, as a consequence of information obtained from this newsletter. Unless you are medically qualified, you should not diagnose your own condition, or the condition of others. You should always consult a medical practitioner (such as a GP or a specialist) for advice about these matters.

Never disregard professional medical advice or delay in seeking it because of something you have read here.

Opinions and views expressed in letters and articles in this newsletter may not necessarily represent the views of the Whirled Foundation Inc. or the editors of Equilibrium.

Whirled Foundation Inc., its Committee of Management, and the editors of Equilibrium expressly disclaim any and all liability resulting from the use of information published in any edition of Equilibrium.

WHIRLED FOUNDATION

ABN 30 128 195 371

Address Suite 4, Brockwood House,

424-426 Nepean Hwy, Frankston, Vic. 3199

Phone 1300 368 818 or (03) 9783 9233

Email [email protected]

Fax (03) 9783 9208

Web www.whirledfoundation.org

Whirled Foundation welcomes articles from health and other professionals, personal stories, letters to the editor, recipes and other articles related to vestibular disorders, and the management strategies for vertigo tinnitus and hearing loss.Material for publication needs to be received by the dates as listed below.(Insert fee covers insertion only, not printing)For contact details regarding the submission of material, see contact details below.

Issue Copy DeadlineAutumn 1st FebruaryWinter 1st May Spring 1st AugustSummer 1st November

AdvertisementsFull page $300 (+ GST)Half page $200 (+ GST)Third of a page $150 (+ GST)Quarter page $100 (+ GST)Inserts (A4) $200 (+ GST)Brochures 3 fold $200 (+ GST)

Equilibrium copy deadlines

Whirled Foundation office hours have changedThough we have made some changes to our office staffing arrangements, you will be able to contact us by phone as normal from Monday to Friday 9.00am – 4.30pm.

However, if you wish to visit us in the Frankston office, or just drop in, the new office opening hours are as follows:

Monday 9.00am – 2.00pm

Wednesday 9.00am – 2.00pm

Friday 9.00am – 2.00pm

A reminder of our new address The Whirled Foundation office is located at:

Suite 4, Brockwood House,

424-426 Nepean Hwy,

Frankston, Vic. 3199

Our new email address is: [email protected]

Our phone numbers remain unchanged.

Phone 1300 368 818 or (03) 9783 9233

Fax (03) 9783 9208

equilibrium - cdn-au.mailsnd.com

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