migrainous vertigo dr mark lewis my nsc. migrainous vertigo outline case studies (migraine)...
TRANSCRIPT
Migrainous Vertigo
Dr Mark Lewis
MY NsC
Migrainous VertigoOutline
• Case studies• (Migraine)• Terminology• Pathophysiology• Epidemiology• Clinical features• Investigations• Differential diagnosis• Treatment
Case 1
• 48y, female, 10 year history• Attacks of vertigo lasting hours to days
• Associated hearing change• Bilateral tinnitus
• Positional symptoms• In between, sense of disequilibrium• PMHx, depression, anxiety
Case 1
• S/B ENT, psychiatry, cardiology, neurology• Diagnosed with Meniere’s, BPPV &
anxiety• Ix
• Mild SN hearing loss• Normal MRI
Case 2
• 72y, female, 20 year history• Episodic attacks of dizziness• More recently, constant bobbing - “boat”• PMHx, diabetes
Case 2
• S/B ENT, elderly medicine, neurology• Diagnosed with Labyrinthitis & later
Meniere’s• Ix
– Moderate asymmetrical hearing loss– MRI - normal
Case Studies
• Case 1• Meniere’s• BPPV• Anxiety
• Case 2• Labyrinthitis• Meniere’s
• Happy?• TBC
Migrainous VertigoOutline
• Case studies• (Migraine)• Terminology• Pathophysiology• Epidemiology• Clinical features• Investigations• Differential diagnosis• Treatment
Migraine
• 8-13% prevalence (~80% without aura)• female predominance (~2:1)• 5% of men at all ages• 10% of women at menarche
– 30% peak at ~35yrs
Migraine
• IHS criteria• A. At least 5 attacks fulfilling B-D• B. Headache attacks lasting 4-72 hours• C. Headaches having at least 2 of the following:
» Unilateral location» Pulsating quality» Moderate or severe intensity» Aggravated by physical activity
• D. No other diagnosis to explain the headache
– Remember – research criteria!
Migraine pathophysiology
Migrainous Vertigo
– Terminology• Migraine associated vertigo• Migraine-related vestibulopathy• Vestibular migraine• Benign recurrent vertigo• Basilar type migraine (?other symptoms)• (Benign paroxysmal vertigo of childhood)• etc
Vestibular Migraine
– Terminology• Migrainous vertigo• Migraine associated vertigo• Migraine-related vestibulopathy• Benign recurrent vertigo• Basilar type migraine (?other symptoms)• (Benign paroxysmal vertigo of childhood)• etc
Vestibular Migraine
• Pathophysiology• Uncertain• ?hypoperfusion of the labyrinth• ?Spreading depression – vestibular cortex
» ?complex nystagmus not explained by this
• ?neurotransmitter release• ?ion channels
– Now brainstem up (like migraine itself)– “Sensitivity sysndrome”
VM pathophysiology
Vestibular Migraine
– Epidemiology– Menieres 0.2% v migraine ~13%– Migraine over represented in patients with:
» BPPV ~50% in those <50y» Menieres ~50%» & vice-versa
– “Migraine” clinics» 27-42% report episodic vertigo» Of these 36% vertigo in headache free period (rest
just before or during)– “Dizzy” clinics
» 16-32% have migraine– Motion sickness ~50% of migraine sufferers (cf ~5-20%)
Vestibular Migraine
– Epidemiology (contd)– Commonest cause of recurrent spontaneous vertigo– Second commonest vestibular disorder in specialist
clinics (5-10%)
Vestibular Migraine
– Clinical features• Attacks of variable duration
– Spontaneous vertigo– Positional vertigo– Head motion intolerance / discomfort– ?Migrainous symptoms
» Headache» Photophobia / phonophobia etc» Aura» Precipitants (foods, poor sleep, hormonal, etc, etc)» “Soft markers”
» Undeserved hangovers, motion sensitivity, yawning, neck ache, visual vertigo, MDD etc
Vestibular Migraine
– History• Need to ask specifically• ?Dizziness diary (for precipitants etc)• Different to aura of a migraine
– Few seconds to weeks!» 20-30% have attacks lasting 5-60 mins (ie aura like)» 50-70% attacks for hours or days» Can fluctuate
• Cochlear symptoms ?10-40%» Hearing loss, tinnitus, aural fullness! (mild and non-
progressive)
Vestibular Migraine
– Examination• Usually normal between attacks
» (Repeated) attacks can cause vestibular damage
• During attack» ? All types of nystagmus» Ataxia» Others
Vestibular Migraine
• Barany Society – IHS Criteria• VM
– A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours
– B. Migraine current or previous (IHS criteria)– C. At least one of the following symptoms during at least 50% of
the vertiginous attacks:» Migrainous headache» Photophobia» Phonophobia» Visual aura
– D. Not better accounted for by another vestibular or ICHD diagnosis
Vestibular Migraine
• Barany Society – IHS Criteria• Probable VM
– A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours
– B. Either or PMHx of migraine or migrainous features during episode
– C. Not better accounted for by another vestibular or ICHD diagnosis
– Remember – Research criteria!!
– Chronic VM??– “on a boat”, “swaying”, constantly off balance with
exacerbations, etc
Vestibular Migraine
• Investigations• Audiometry• First attack – probably imaging• (?Nystagmography)• (?VEMPs)• (??Otoacoustic emission suppression)
Vestibular Migraine
• Differential diagnosis• Non-specific migrainous “dizziness”
» ?postural hypotension» ?other
• Meniere’s» Duration of attacks» Progression of hearing loss» Very “migrainous => migraine» Very “menieres” => menieres
Vestibular Migraine
• Differential diagnosis• POCS TIAs
» Presence of migrainous features» Lack of risk factors» Young age» Long attacks with complete recovery» Frequent attacks with no “stroke”» Long history of attacks with no “stroke”
• Vestibular paroxysmia» Very short» Daily occurrence» High frequency» Response to CBZ
• Other neurological disorders (EA, cerebellar etc)• ?(“Cervical vertigo”)
Vestibular Migraine
• Treatment• EXPLANATION• Avoidance of triggers• Acute
» Analgesics» Pro-kinetic anti-emetics» Vestibular sedatives» Migraine specific treatments (Rizatriptan)
Vestibular Migraine
• Treatment– Prophylaxis
• Frequent or prolonged attacks (or chronic)– Usual
» Amitriptyline» Propranalol» Pizotifen» Topiramate» Na Valproate» Lamotrigine» etc
Case Studies
• Case 1• Meniere’s• BPPV• Anxiety
• Case 2• Labyrinthitis• Meniere’s
Case Studies
• Case 1• Meniere’s• BPPV• Anxiety
• Case 2• Labyrinthitis• Meniere’s
• ? Either / both / neither - VM
Three Things
• BPPV• VM• Uncompensated vestibular dysfunction
– eg previous VN, on stemetil for 20 years!!