Vestibular migraineBMJ 2019; 366 doi: https://doi.org/10.1136/bmj.l4213 (Published 03 July 2019) Cite this as: BMJ 2019;366:l4213
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The authors give a welcome introduction to a common and disabling condition. Importantly they mention that anxiety is a common co-morbidity and panic attacks occur during a vestibular migraine episode and is a risk factor for chronification. Consider anxiety is described in more than 50% screening with for example a GAD-7 (freely available online) is highly recommended (Minen, M.T., Dhaem, O.B.D., Diest, A.K.V., Powers, S., Schwedt, T.J., Lipton, R. and Silbersweig, D. (2016) ‘Migraine and its psychiatric comorbidities’, Journal of Neurology, Neurosurgery and Psychiatry. DOI: 10.1136/jnnp-2015-312233.).
The authors miss out on the evolving literature on Persistent Postural-perceptual dizziness (PPPD). (see Popkirov et al,, Persistent postural-perceptual dizziness (PPPD): a common, characteristic and treatable cause of chronic dizziness. Pract Neurol. 2018 Feb;18(1):5-13 for a review). In that common condition there are more chronic symptoms of unsteadiness and dizziness. Vestibular migraine often plays an important role in PPPD (either as a trigger and/or perpetuating factor) but only addressing as migraine (and labelling it as such) is often not successful in my experience (which can require addressing anxiety with CBT and/or medication, understanding the condition and vestibular rehabilitation.
The notes in the International Clasification for Headache disorders criteria (IHCD-3) clearly demonstrate the lack of clarity of duration of attacks (Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours.) These notes illustrate the difficulty with determining duration of episodes of vestibular migraine and the likely overlap with PPPD
I strongly feel that in patients with more chronic symptoms a biopsychosocial approach (as done in PPPD) is likely to help more than the isolated label of vestibular migraine (which often leads more to pharmacological management approaches).
This does not take anything away from the fact as the authors have made clear that vestibular migraine is common, important and treatable.
Competing interests: No competing interests
The relationship between migraine and vertigo was recognized by some of the first neurologists in the nineteenth century, however systematic studies on vertigo caused by migraine began only 100 years later. In the last three decades vestibular migraine has taken shape as a clinical entity that can affect up to 1% of the general population. Despite this recognition, the lack of a universally accepted definition has made it difficult to identify these patients in the clinical and research settings.
Migraine and recurrent vertigo are two very frequent reasons for consultation in primary care, and cause a health problem of great magnitude with both personal and socio-labor repercussions. In Europe, migraine has a prevalence of 14%, while vestibular vertigo affects 7.4% of the general population at some point in their lives. These two symptoms often coexist in the same patient. Several case-control studies have shown that dizziness and vertigo are more frequent in patients with migraine compared to controls adjusted for age and sex.
Patients with vertigo, especially those without an accurate diagnosis, suffer more frequently migraine than the corresponding controls. If this comorbidity were by simple chance, the expected prevalence throughout life would be 1.1%; However, epidemiological studies at the population level have found a prevalence of 3.2%. Given this fact, the clinician who faces a patient with migraine and recurrent vestibular symptoms must determine what disorder the patient presents. If it is a mere coincidence, or if it is a vestibular migraine, or if it corresponds to a benign paroxysmal positional vertigo or a Menière's disease, which are two entities that are epidemiologically related to migraine, and that sometimes, they are difficult to distinguish from vestibular migraine, since they show a certain degree of overlap with it.
Until now, different terms have been used to refer to this clinical entity: migrainous vertigo, vertigo or dizziness associated with migraine, vestibulopathy related or induced by migraine. All these terms, although synonymous, should be avoided, using the vestibular migraine instead. Many of the patients diagnosed with benign recurrent vertigo or vestibular Menière's disease probably also correspond to this same entity, especially if they suffer from migraine.
Currently, and as with migraine, we do not have a biological marker to diagnose vestibular migraine. Several authors have proposed diagnostic criteria for vestibular migraine from the clinical history, the most accepted so far being those established by Neuhauser et al., Which distinguish between definitive and probable vestibular migraine. A structured clinical interview model for vestibular migraine has also been developed. In this issue of Otorhinolaryngology Act, the Spanish version of the vestibular migraine definition is presented, which is a consensus document of the Bárány Society and the International Headache Society (IHS).
The Bárány Society is an international association formed by professionals from various disciplines (otolaryngologists, neurologists, physiotherapists, psychiatrists, psychologists, engineers, neurophysiologists and basic researchers) interested in the promotion of research and knowledge of the vestibular system. In 2008, a group of neurologists and otolaryngologists formed a Committee to develop an International Classification of Vestibular Disorders, with the aim of establishing clinical criteria for diagnosis of the most frequent disorders following the IHS model for the definition of headaches ( International Classification of Headache Disorders [ICHD]).
The current definition includes two diagnostic categories: vestibular migraine and probable vestibular migraine, having eliminated the possible vestibular migraine category that appeared in the first drafts. The definition of vestibular migraine has gained considerably in precision because it requires a minimum of five episodes of vestibular symptoms, a personal history of migraine according to the criteria of the IHS (the family history has disappeared as an alternative criterion), and that at least 50% of episodes of vestibular symptoms are associated with migraine (at least 3 episodes of migraine associated with vestibular symptoms). In addition, if another vestibular disease (Meniere's disease) or the diagnosis attributable ICHD (basilar migraine type), should not be diagnosed patient vestibular migraine.
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Competing interests: No competing interests