1. Migrainous Vertigo Dr Mark Lewis MY NsC

2. Migrainous Vertigo Outline Case studies (Migraine) Terminology Pathophysiology Epidemiology Clinical features Investigations Differential diagnosis Treatment

3. Case 1 48y, female, 10 year history Attacks of vertigo lasting hours to days Associated hearing change Bilateral tinnitus Positional symptoms In between, sense of disequilibrium PMHx, depression, anxiety

4. Case 1 S/B ENT, psychiatry, cardiology, neurology Diagnosed with Meniere’s, BPPV & anxiety Ix Mild SN hearing loss Normal MRI

5. Case 2 72y, female, 20 year history Episodic attacks of dizziness More recently, constant bobbing - “boat” PMHx, diabetes

6. Case 2 S/B ENT, elderly medicine, neurology Diagnosed with Labyrinthitis & later Meniere’s Ix –Moderate asymmetrical hearing loss –MRI - normal

7. Case Studies Case 1 Meniere’s BPPV Anxiety Case 2 Labyrinthitis Meniere’s Happy? TBC

8. Migrainous Vertigo Outline Case studies (Migraine) Terminology Pathophysiology Epidemiology Clinical features Investigations Differential diagnosis Treatment

9. Migraine 8-13% prevalence (~80% without aura) female predominance (~2:1) 5% of men at all ages 10% of women at menarche –30% peak at ~35yrs

10. Migraine IHS criteria A. At least 5 attacks fulfilling B-D B. Headache attacks lasting 4-72 hours C. Headaches having at least 2 of the following: »Unilateral location »Pulsating quality »Moderate or severe intensity »Aggravated by physical activity D. No other diagnosis to explain the headache –Remember – research criteria!

11. Migraine pathophysiology

12. Migrainous Vertigo –Terminology Migraine associated vertigo Migraine-related vestibulopathy Vestibular migraine Benign recurrent vertigo Basilar type migraine (?other symptoms) (Benign paroxysmal vertigo of childhood) etc

13. Vestibular Migraine –Terminology Migrainous vertigo Migraine associated vertigo Migraine-related vestibulopathy Benign recurrent vertigo Basilar type migraine (?other symptoms) (Benign paroxysmal vertigo of childhood) etc

14. Vestibular Migraine Pathophysiology Uncertain ?hypoperfusion of the labyrinth ?Spreading depression – vestibular cortex »?complex nystagmus not explained by this ?neurotransmitter release ?ion channels –Now brainstem up (like migraine itself) –“Sensitivity sysndrome”

15. VM pathophysiology

16. Vestibular Migraine –Epidemiology –Menieres 0.2% v migraine ~13% –Migraine over represented in patients with: »BPPV ~50% in those <50y »Menieres ~50% »& vice-versa –“Migraine” clinics »27-42% report episodic vertigo »Of these 36% vertigo in headache free period (rest just before or during) –“Dizzy” clinics »16-32% have migraine –Motion sickness ~50% of migraine sufferers (cf ~5-20%)

17. Vestibular Migraine –Epidemiology (contd) –Commonest cause of recurrent spontaneous vertigo –Second commonest vestibular disorder in specialist clinics (5-10%)

18. Vestibular Migraine –Clinical features Attacks of variable duration –Spontaneous vertigo –Positional vertigo –Head motion intolerance / discomfort –?Migrainous symptoms »Headache »Photophobia / phonophobia etc »Aura »Precipitants (foods, poor sleep, hormonal, etc, etc) »“Soft markers” »Undeserved hangovers, motion sensitivity, yawning, neck ache, visual vertigo, MDD etc

19. Vestibular Migraine –History Need to ask specifically ?Dizziness diary (for precipitants etc) Different to aura of a migraine –Few seconds to weeks! »20-30% have attacks lasting 5-60 mins (ie aura like) »50-70% attacks for hours or days »Can fluctuate Cochlear symptoms ?10-40% »Hearing loss, tinnitus, aural fullness! (mild and non- progressive)

20. Vestibular Migraine –Examination Usually normal between attacks »(Repeated) attacks can cause vestibular damage During attack »? All types of nystagmus »Ataxia »Others

21. Vestibular Migraine Barany Society – IHS Criteria VM –A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours –B. Migraine current or previous (IHS criteria) –C. At least one of the following symptoms during at least 50% of the vertiginous attacks: »Migrainous headache »Photophobia »Phonophobia »Visual aura –D. Not better accounted for by another vestibular or ICHD diagnosis

22. Vestibular Migraine Barany Society – IHS Criteria Probable VM –A. At least 5 episodes with vestibular symptoms of moderate or severe intensity, lasting 5 mins to 72 hours –B. Either or PMHx of migraine or migrainous features during episode –C. Not better accounted for by another vestibular or ICHD diagnosis –Remember – Research criteria!! –Chronic VM?? –“on a boat”, “swaying”, constantly off balance with exacerbations, etc

23. Vestibular Migraine Investigations Audiometry First attack – probably imaging (?Nystagmography) (?VEMPs) (??Otoacoustic emission suppression)

24. Vestibular Migraine Differential diagnosis Non-specific migrainous “dizziness” »?postural hypotension »?other Meniere’s »Duration of attacks »Progression of hearing loss »Very “migrainous => migraine »Very “menieres” => menieres

25. Vestibular Migraine Differential diagnosis POCS TIAs »Presence of migrainous features »Lack of risk factors »Young age »Long attacks with complete recovery »Frequent attacks with no “stroke” »Long history of attacks with no “stroke” Vestibular paroxysmia »Very short »Daily occurrence »High frequency »Response to CBZ Other neurological disorders (EA, cerebellar etc) ?(“Cervical vertigo”)

26. Vestibular Migraine Treatment EXPLANATION Avoidance of triggers Acute »Analgesics »Pro-kinetic anti-emetics »Vestibular sedatives »Migraine specific treatments (Rizatriptan)

27. Vestibular Migraine Treatment –Prophylaxis Frequent or prolonged attacks (or chronic) –Usual »Amitriptyline »Propranalol »Pizotifen »Topiramate »Na Valproate »Lamotrigine »etc

28. Case Studies Case 1 Meniere’s BPPV Anxiety Case 2 Labyrinthitis Meniere’s

29. Case Studies Case 1 Meniere’s BPPV Anxiety Case 2 Labyrinthitis Meniere’s ? Either / both / neither - VM

30. Three Things BPPV VM Uncompensated vestibular dysfunction –eg previous VN, on stemetil for 20 years!!