Definition and Overview
Vestibular migraine (VM) is a disease in which recurrent vestibular symptoms occur in patients who meet the clinical criteria for migraine. The International Headache Society (IHS) and the Bárány Society jointly established diagnostic criteria, and it is one of the most common causes of recurrent dizziness.
Approximately 7-11% of patients at dizziness clinics are diagnosed with vestibular migraine, and approximately 1% of the general population has the disease. It occurs approximately 1.5 to 5 times more often in women than in men, and occurs mainly in people in their 30s to 50s. It is reported that approximately 10-36% of migraine patients are accompanied by vestibular symptoms.
Diagnostic criteria
The criteria for definite vestibular migraine (definite VM) according to the 2012 IHS-Bárány Society joint diagnostic criteria are as follows.
A. Current or past history of migraine (with or without aura) according to the International Classification of Headache Disorders. B. Five or more attacks of moderate to severe vestibular symptoms, lasting between 5 minutes and 72 hours. c. More than half of the attacks are accompanied by one or more of the following migraine symptoms: migraine headache, sensitivity to light, sensitivity to sound, or visual auras. D. Not better explained by another vestibular disorder or ICHD diagnosis.
Possible vestibular migraine (probable VM) is a case that partially meets the above criteria but does not meet the definitive criteria.
Characteristics of vestibular symptoms
The vestibular symptoms that occur in vestibular migraine are diverse. Spontaneous vertigo is dizziness with a feeling of rotation or linear movement. Positional vertigo occurs when the head position changes and needs to be differentiated from BPPV. Head motion-induced dizziness is dizziness that gets worse when you exercise your head. Visually induced vertigo occurs when exposed to moving objects or complex visual environments. Postural instability and balance disorders are also included.
The duration of vestibular symptoms varies from less than 5 minutes to 72 hours, most often minutes to several hours.
Mechanism of occurrence
Although the exact mechanism of vestibular migraine is not known, the neural connection between the pathophysiology of migraine and the vestibular system is understood to be key.
Cortical spreading depression (CSD) may involve the vestibular cortex region. CGRP (calcitonin gene-related peptide) is a major neurotransmitter in migraine and is known to act on the vestibular nuclei and inner ear (cochlea). Trigeminal activity appears to influence vestibular signals through the trigemino-vestibular connection.
The serotonin system is also involved. Various serotonin receptors are expressed in the vestibular nuclei, so serotonin changes in migraine may cause vestibular symptoms.
Differentiation from Meniere's disease
It is important to differentiate between vestibular migraine and Meniere's disease because they both cause repeated attacks of vertigo.
The characteristic findings of Meniere's disease are three symptoms: unilateral sensorineural hearing loss (especially low-frequency hearing loss), tinnitus, and ear fullness. Dizziness usually lasts from tens of minutes to several hours. On the other hand, vestibular migraine is accompanied by migraine symptoms and has no or mild hearing problems. However, since the two diseases can coexist, it is difficult to differentiate them.
Hearing test, vestibular evoked muscle potential (VEMP), video head impulse test (vHIT), and caloric test help in differentiation.
treatment
Acute Attack Treatment
During attacks, triptans such as sumatriptan can be effective for both headaches and dizziness. Antiemetics (metoclopramide) and vestibular suppressants (diazepam, meclizine) are used to relieve acute symptoms. Remain calm during a attack and minimize visual stimulation.
preventive care
If attacks are frequent (more than twice a month), severe, or cause severe functional impairment, begin preventive treatment. Migraine preventive drugs such as topiramate, valproic acid, amitriptyline, and beta blockers (propranolol, metoprolol) are also effective for vestibular migraine. CGRP-targeting monoclonal antibodies (erenumab, galcanezumab) have also been reported to be effective in preventing vestibular migraine.
Non-pharmacological treatment
Vestibular rehabilitation treatment helps improve postural instability and balance disorders between attacks. Lifestyle management (regular sleep, regular eating, restriction of caffeine and alcohol, stress management) contributes to reducing attacks.