Vestibular migraine

Despite 40% of migraine sufferers experiencing some form of dizziness or disruption to balance, vestibular migraine (VM) has really only been acknowledged over the past two decades.

Migraine is a well-known, specific clinical syndrome yet it remains incompletely defined. Migraine, seen as a neurological event as opposed to a vascular event, is more prevalent in females (approximately 3x), and is most likely to occur between the ages of 35-45 years old.

The basic presentation of a migraine includes:

• One-sided onset of throbbing headache
• Often referred to as a “sick headache”
• Photophobia (sensitivity to light)/phonophobia (sensitivity to sound)
• Visual aura

Perhaps the reason for migraine definitions remaining incomplete is that migraine presentations are so variable. Vertigo and dizziness duration vary from seconds to days, with frequency varying from daily to yearly. Not all VM sufferers have associated headaches, and it is believed that vertigo can actually take the place of headaches in some cases.

VM is a common cause of vertigo, and it may present rotational, non-rotational, spontaneous or with position changes. Most often, migraine causes spontaneous vertigo, as opposed to positional vertigo (such as with BPPV), and most times, migraine onset is before vestibular symptoms.

Often, migraine presentations can be similar to Meniere’s disease –

This table gives some distinguishable differences.

As the table above indicates, migraine has a strong association with both motion sickness, and this often gets worse with age. The older client will also be more likely to have more than one vestibular diagnosis, and therefore will have more than one cause of vertigo, e.g BPPV with VM.

There are no tests for migraine, and upon vestibular examination and investigation it is common that most assessments are normal. Diagnosis of VM is made when at least 5 episodes with vestibular symptoms of moderate to severe intensity have occurred, lasting anywhere between 5 minutes to 72 hours. Guidelines also specify that VM diagnosis is made when the presentation is not better accounted for by another vestibular disorder.

Dietary triggers for migraine which can be avoided in a pro-active approach to migraine care. Some common triggers are listed below:

• Alcohol
• MSG
• Chocolate
• Caffeine
• Processed meats
• Processed cheese
• Artificial sweetners

It is also recommended that migraine sufferers avoid nicotine, reduce stress, and possibly follow a migraine diet.

Therapy for VM sufferers can be very effective. It is often a combination of effective medication (which requires trial and error) and habituation exercises, aimed at progressive, repetitive exposure to symptom-provoking visual motion. Habituation is indicated especially for those with head or visual motion-provoked symptoms and must be persistent and gentle, with gradual changes to the level of challenge.