Migraine Associated Vertigo (MAV)

Timothy C. Hain, MD
Last edited: 5/4/2002

• What is Migraine Associated Vertigo?
• What Causes Migraine Associated Vertigo?
• How is Migraine Associated Vertigo Diagnosed?
• How is Migraine Associated Vertigo Treated?
• Research Studies on Migraine Associated Vertigo
• Acknowledgments
• References

What is Migraine Associated Vertigo?

Migraine Associated Vertigo is dizziness that is associated with a migraine headache condition. Dizziness and headache are individually very common human conditions and their combination is also a common symptom complex. Diagnostically, one must determine whether the dizziness and headaches are independent or related to each other, and in particular, whether they are a manifestation of migraine. Here we will review the association between vertigo and migraine. This subject has also been recently reviewed by Cass and associates (1997).

How Common is Migraine Associated Vertigo?

According to Stewart and associates (1994), nearly 10% of the entire population of the United States has migraine. There is a male-to-female distribution difference. At all ages, about 5% of men have migraine. Women of childbearing age have a much higher prevalence, jumping up to roughly 10% at the onset of menstruation, and increasing to nearly 30% at the peak age of 35 years. At menopause, rates of migraine abruptly decline in women back to roughly 10%. The prevalence of migraine is far higher than that of Meniere's disease, which occurs in only 0.2% of the United States population (Wladislavosky-Waserman et al, 1984).

In practices focused on treating migraine, 27 to 42 % of patients report episodic vertigo (see Table 1). A large number (about 36%) of these patients experienced vertigo during headache-free periods. The remainder experienced vertigo either just before or during the headache. The incidence of vertigo during the headache period was higher in patients with aura (sensations such as seeing colors, hearing voices, or numbness) as opposed to in those without aura.

Motion sickness is a common migraine accompaniment. Most studies report about 50% of patients with migraine have motion sickness, compared to about 5 to 20% for control groups.

Syncope can also accompany migraine, and this offers another entirely separate mechanism for dizziness in migraine. In migraine, hypotension is likely hormonal, and is attributed mainly to vasopressin (Gupta, 1997).

Figure 1A. Fortification spectra, as might be seen in Migraine with aura.

Figure 1B. Scotoma with aspects of a fortification.

What are the Symptoms of Migraine Associated Vertigo?

Migraine without aura (about 80%) and migraine with aura (about 15 to 20%) are the most prevalent forms of migraine and also are the most prevalent types of migraine associated with dizziness and vertigo. Figure 1A and B show some examples of typical migraine auras. Symptoms include true vertigo with or without nausea and vomiting, and motion intolerance. Headache is usual but not required. Auditory symptoms are common but usually bilateral. Hyperacusis is common in migraine, which may differentiate it from most ear disorders. When patients are examined acutely when vertiginous, there is usually minimal or no spontaneous nystagmus (jumping of the eyes). This provides a differential feature from most peripheral vestibular syndromes.

Timing. Cutrer and Baloh (1992) found a bimodal distribution of duration of vertigo with 31% of individuals having spells that typically lasted a few minutes to 2 hours and 49% having spells that lasted longer than 24 hours. Therefore by duration, these episodes could be confused with those due to BPPV, Meniere's disease, or even vestibular neuritis.

Headache is not required to make the diagnosis of MAV. As in migraine, occasionally aura may occur without headache (acephalgic migraine); it also follows that vertigo may occur without headache.Benign recurrent vertigo(BRV) of adults, essentially a vertiginous migraine aura without headache, was described first by Slater (1979). It consists of spells of vertigo, which can include tinnitus, but without hearing loss (were hearing loss allowed, this disorder would become very difficult to distinguish from Meniere's disease). Vertigo lasts from minutes to hours. Not all authors agree that BRV is caused by migraine however, and Leliever and Barber suggested that it is caused by peripheral vestibular lesions (1981).

Another example of MAV is the benign paroxysmal vertigo syndrome of children, where headache does not occur. Cutrer and Baloh (1992) also observed that dizziness and headaches are not necessarily closely associated. In fact, in their 91 patients, only 5 had a consistent recurring dizziness with headache. In 30%, dizziness was consistently independent of headache. In most, spells sometimes occurred with and sometimes independently.

Basilar migraine, also known as Bickerstaff's syndrome (1961), consists of two or more symptoms (vertigo, tinnitus, decreased hearing, ataxia, dysarthria, visual symptoms in both hemifields of both eyes, diplopia, bilateral paresthesias or paresis, decreased consciousness or loss of consciousness) followed by a throbbing headache. Vertigo typically lasts between five minutes and one hour. In the author?s practice, the typical patient is a woman of about 35 years of age, who attacks of vertigo combined with headache. The family history is often positive. In the differential are transient ischemic attacks (TIAs) and paroxysmal vestibular disorders accompanied by headache. Patients usually respond to diet changes or the usual prophylactic drugs (see below).

Auditory symptoms are rare compared to vestibular symptoms, but nevertheless there is good evidence that hearing loss and tinnitus do occur. Olsson (1991) in a study of 50 patients with basilar migraine (which is rare) documented a fluctuating low-tone sensorineural hearing loss in more than 50% of his patients, and about 50% of his patients noticed a change in hearing immediately prior to their migraine headaches. Virre and Baloh (1996) suggested that sudden hearing loss may also be caused by migraine. Tinnitus is also common in migraine (Kayan and Hood, 1984; Olsson, 1991). Because the formal criteria for Meniere's disease [audiometrically documented hearing loss (not fluctuation), episodic tinnitus and/or fullness, episodic vertigo] are a subset of the documented spectrum of basilar migraine, there is the possibility for diagnostic ambiguity (Harker, 1996). When headache is not prominent, features such as bilateral hearing fluctuation [according to Harker (1996) auditory symptoms are rarely unilateral], family history of migraine and perimenstrual exacerbations are used to decide whether Meniere's disease or migraine is the more likely diagnosis.

Benign paroxysmal vertigo of childhood, is a disorder of uncertain origin, possibly migrainous. Its initials (BPV) are easily confused with those of benign paroxysmal positional vertigo (BPPV), but it is not caused by the same mechanisms. BPV consists of spells of vertigo and disequilibrium without hearing loss or tinnitus (Basser, 1964). The majority of reported cases occur between one and four years of age, but this syndrome seems indistinguishable from benign recurrent vertigo (BRV, see following) in adults which is presently attributed to migraine, or so-called "vestibular Meniere's," which is also attributed to migraine. The differential diagnosis includes Meniere's disease, vestibular epilepsy, perilymphatic fistula, posterior fossa tumors, and psychogenic disorders.

Familial syndromes. There has recently been a report of a familial vestibulopathy, called familial Benign Recurrent Vertigo (BRV) consisting of episodic vertigo with or without migraine headache. Presumably there are both familial and nonfamilial forms. The nonfamilial form is sometimes called recurrent vestibular neuritis as well as vestibular Meniere's.

Vestibular testing in the familial form can document profound bilateral vestibular loss. The familial syndrome responds to acetazolamide (Baloh et al, 1994). It is not associated with a mutation on the calcium channel gene (Oh et al, 2001). Also reported by Baloh and associates, a form exists with episodic vertigo and essential tremor. This form is also responsive to acetazolamide. (Baloh et al, 1996). Familial hemiplegic migraine has been linked to mutations in the calcium channel gene (Ophoff et al, 1996). French-Canadian intermittent ataxia syndrome also may present similarly. While no mutations have been identified in the common form of migraine, calcium channels could be functionally impaired by subtle gene changes such as polymorphisms.

Antiphospholipid antibodies. While controversial, there are some reports that individuals with severe migraine headaches are more likely to have antiphospholipid antibodies. In the authors experience, these patients may present with transient monocular visual loss, and some also have fetal wastage and complicated migraines. (Donders et al, 1998)

What Causes Migraine Associated Vertigo?

At this writing (5/2002), the underlying cause for migraine and thus migraine associated vertigo remains unclear. It is presently thought that migraine reflects the action of a common gene in the population, that is related to pain control, and also to a neurotransmitter called "serotonin".

How is Migraine Associated Vertigo Diagnosed?

There are no diagnostic tests specific for migraine associated vertigo. The diagnosis is made by clinical history, or when the history is unclear, by a therapeutic response to treatment. A definite diagnosis of migraine associated vertigo can be made when patients have migraine with aura that is accompanied by concurrent episodes of vertigo, or when they have migraine without aura that is repeatedly associated with vertigo immediately before or during the headache.

Figure 2: Migraine associated vertigo can sometimes be successfully treated simply by withdrawing chocolate, cheese, alcohol, and foods with MSG from one's diet .

How is Migraine Associated Vertigo Treated?

Eliminating food triggers and prophylactic treatment are the methods used most frequently in treatment. Patients are initially told to abstain from foods such as chocolate, cheese, alcohol, and MSG-containing preparations. If this is not successful, after a month, patients are started on verapamil, or a long-acting beta-blocker such as long acting propranolol or a tricyclic medication such as amitriptyline. Verapamil and amitriptyline are particularly useful because of their anticholinergic properties may help control vertigo independently of whether they are useful for migraine.

Research Studies on Migraine Associated Vertigo

At the end of 2001, a visit to the National Library of Medicine's search engine, Pubmed, revealed 215 research articles concerning Migraine with vertigo published since 1966. This indicates that while migraine associated vertigo has not been ignored, it has not elicited nearly as much attention from the research community as other disorders, such as Meniere's disease. At the American Hearing Research Foundation (AHRF), we have funded basic research on dizziness and balance disorders in the past, and are interested in funding research on migraine associated vertigo in the future. Click here if you would you would like more information about contributing to the AHRF's efforts to manage migraine associated vertigo.

Acknowledgments

Figures 1 and 2 are used courtesy of Northwestern University.

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