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DOI 10.1007/s00405-013-2786-4
OTOLOGY
Received: 11 July 2013 / Accepted: 16 October 2013 / Published online: 29 October 2013
Springer-Verlag Berlin Heidelberg 2013
Introduction
Patients with migraine often complain of dizziness or
vertigo during or in between attacks. Various terminologies
have evolved to describe this condition such as migraineassociated vertigo, migraine-related vestibulopathy, vestibular migraine, or migrainous vertigo [14].
Migrainous vertigo (MV) can be defined as a vestibular
syndrome caused by migraine that can present as spontaneous or positional vertigo lasting seconds to days,
accompanied by migrainous symptoms [1]. Like migraine,
MV is a diagnosis by exclusion and cannot be diagnosed by
specific tests. An operational clinical criterion (definite and
probable) has been proposed based on the IHS classification of headaches [1]. Various authors have emphasized the
migrainous origin of episodic vertigo that can occur even in
the absence of headache [1, 5, 6]. Vestibular migraine has
been recognized as a separate entity from migraine with
brainstem aura (earlier basilar migraine) only recently. A
new set of diagnostic criterion has been proposed jointly by
the Committee for Classification of Vestibular Disorders of
the Barany Society and the Migraine Classification Subcommittee of the International Headache Society (IHS) [7].
A diagnosis of vestibular migraine is considered in the
presence of vestibular symptoms of any type, history of
migraine and a temporal association between the two, all
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Results
The demographic profile of the subjects enrolled is given in
Table 1, and age and sex distribution of subjects is given in
2933
Percentage
Male
18
34.6
Female
34
65.4
Total
52
100
Sex
Age
B24 years
12
23.1
2534 years
23
44.2
C35 years
17
32.7
Total
52
100.0
Control arm
(Arm B)
Total
p value
0.77
Sex
Male
10
18
Female
Total
16
26
18
26
34
52
Age
B24 years
2534 years
C35years
Total
12
14
23
11
17
26
26
52
0.28
Percentage of patients
90
80
70
60
50
40
30
20
10
0
123
2934
p value
Vertigo frequency
High frequencya
11
14
Low frequencya
22
12
34
Total
25
23
48
12
22
25
14
23
36
48
0.010
0.046
Headache frequency
High frequencya
10
18
Low frequencya
17
13
30
Total
25
23
48
0.38
10
16
Marked improvementb
19
13
32
Total
25
23
48
0.22
No adverse
effects
Total
p value
Arm A
19
25
0.248
Arm B
21
23
Total
40
48
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Discussion
Migrainous vertigo is not a rare entity and its prevalence
has been reported as 7 % in a dizziness clinic group and
9 % in a migraine clinic group [1]. It is difficult to
determine the prevalence of MV mainly because the entity
by itself is an evolving concept, and internationally
approved diagnostic criteria were published only in 2012
[8]. The criteria used in this study were proposed by
Neuhauser et al. [1]. Definite MV accounted for only a
third of migraineurs with a history of vestibular vertigo. In
general, the prevalence of MV was higher among women
and highest in the reproductive age group. The demographic profile of our patients (Table 1) are similar to
other studies [19]. At the age of onset of migraine
symptoms, the severity of headache was more and this had
attenuated over time when compared to that of vertigo
which had become more severe. This type of pattern in the
natural course of the disease has been mentioned earlier
[20]. Absence or attenuation of migrainous headache
during vertiginous attacks may be due to an interaction of
vestibular and trigeminal mechanisms [21]. We found that
52.6 % of patients who described their vestibular symptoms as severe also experienced photophobia, phonophobia, visual and other sensory and motor auras. These
phenomena may be of diagnostic importance as they may
represent the only apparent association between vertigo
and migraine. Auditory symptoms and sensorineural
hearing loss in MV are less frequent when compared to
vestibular symptoms [22]. The duration of vertigo attacks
was shorter when compared to that of headaches which
tend to last longer; however, the frequency and severity of
the vertigo spells were comparable to that of the headache.
Vestibular symptoms in MV were manifest as lightheadedness, dizziness, unsteadiness and also spinning type
of vertigo.
Although MV is a common cause of dizziness in
patients, there are very few studies that deal with the
prophylactic treatment of this entity. MV may respond to
the same medications used to treat migraine headaches, but
there is limited data on this [23]. A small randomized trial
using zolmitriptan for aborting attacks in these patients
showed inconclusive results due to the limited power of the
study [10]. Acetazolamide has been reported to improve
symptoms in familial migraine with vertigo and tremor
[24]. It has also been found to be useful in MV in familial
hemiplegic migraine [25]. Retrospective studies on patients
who fit the criteria for MV have shown varying levels of
benefit with drugs such as beta blockers, calcium channel
blockers, tricyclic antidepressants, cyproheptadine, anticonvulsants and benzodiazepines. These have been used
either singly or in various combinations; pharmacological
therapy has also been used in association with dietary
2935
Conclusion
Flunarizine (10 mg) is a useful drug in patients with MV,
especially in those who have significant morbidity due to
their vestibular symptoms. Severity and frequency of
headache in MV are reduced to a less significant extent by
Flunarizine. Compliance is good and side effects are
minimal. We recommend the use of flunarizine as a first
line of treatment in patients who suffer from MV and in
whom vestibular complaints are considerable.
Acknowledgments The authors would like to gratefully acknowledge the contributions of Professor Vinohar Balraj and Ms. Visali in
the statistical analysis of this article. This study was supported by
funding from the Fluid Research Grants, CMC Research, Vellore.
Conflict of interest The authors declare that they have no conflicts
of interest.
Appendix
This questionnaire was based on a similar one used for a
previous study of vestibular deficits among clinically
defined subgroups of patients with both migraine and
vertigo attending tertiary referral neuro-otology clinics.
(By AB under the guidance of Dr Ros Davis and Prof
Goadsby in National hospital for Neurology and Neurosurgery, Queens Square, London, submitted as partial
fulfilment of the requirements for MSc. in Audiological
Medicine, University College London.)
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