Download Migraine Associated Dizziness

Migraine Associated Dizziness
Robert A. Battista, M.D.
Ear Institute of Chicago
Hinsdale, IL
Assistant Professor
Department of Otolaryngology
Northwestern University Medical School
Migraine Associated Dizziness
•  Case report
I.  Migraine overview
II.  Define/Characterize Migraine Dizziness
III.  Treatment for Migraine Dizziness
IV.  Summary
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Case Study (patient DA)
—  35 y.o. F, dizzy for 25 months
—  Initial attack: vertigo, 24hrs; then imbalance
for weeks
—  Vertigo occurs spontaneously, several attacks
per month; lightheaded between
—  Severe motion intolerance
—  Left aural fullness for 2 months
—  No hearing loss/ Bilateral tinnitus
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Case Study (patient DA)
—  Dizziness began with use of birth control
pills
—  No past history of headache, aura
—  Family history: mother with migraine
—  Verapamil: unable to tolerate
—  Nortriptyline: no dizziness for 2 years
Meniere s Disease: Diagnosis
—  Definite: > 2 vertigo episodes, sensorineural
hearing loss (SNHL), tinnitus/aural fullness,
other causes excluded
—  Probable: 1 episode of vertigo, SNHL, tinnitus/
aural fullness
—  Possible
—  Episodic vertigo w/o SNHL or
—  SNHL w/ dysequilibrium
(1995 AAO-HNS Committee Hearing & Equilibrium)
IHS Classification of Migraine
1.1. Migraine without aura
1.2. Migraine with aura
1.2.1. Migraine with typical aura
1.2.2. Migraine with prolonged aura
1.2.4. Basilar migraine
1.2.5. Migraine aura without headache
1.3. Ophthalmologic migraine
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Migraine without Aura
(Common Migraine)
—  5 attacks lasting 4-72 hrs
—  2 of the following:
—  Unilateral location
—  Pulsating quality
—  Moderate/severe intensity
—  Aggravation with physical activity
—  1 of the following:
—  Nausea and/or vomiting
—  Photo or phonophobia
—  Normal neurological exam/other causes
excluded
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Migraine with Aura
(Classic Migraine)
—  2 or more attacks
—  Headache as with common migraine
—  Aura characteristics
—  Fully reversible
—  Gradual onset
—  < 60 minutes
—  HA free interval < 60 minutes or HA starts
before or during aura
—  Normal neurological exam/other causes
excluded
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University
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Northwestern
University
Basilar Migraine
—  Meets criteria for Migraine with Aura
—  2 or more of the following:
—  Visual symptoms (both eyes)
—  Slurred speech
—  Vertigo
—  Tinnitus
—  Decreased hearing
—  Double vision
—  Unsteady gait
—  Bilateral limb numbness
—  Decreased consciousness
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Migraine Diagnostic Features
—  Headache (95%)
—  Nausea or vomiting (80%)
—  Complete relief after sleep (90+%)
—  Phonophobia/photophobia
—  Motion sickness (50%)
—  Food triggers (MSG, Alcohol, Chocolate)
—  Family history (50%)
—  Aura (10%)
Migraine Aura
—  Aura
—  Develops over 5 – 20 minutes
—  Duration: 5 – 60 minutes (6-12% > 1 hr)
—  !
Significant neurological dysfunction of
visual, somatosensory, motor, speech,
brainstem function"
*
*Migraine, 2nd ed., R. Davidoff, Oxford Press, 2002
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Migraine: Other Auras
—  Scotoma
—  Unilateral parethesias or numbness
—  Unilateral weakness
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Migraine Prodrome
—  Prodrome (7-88% of migraineurs*)
—  Insidious development
—  Duration: Hrs to days
—  Numerous manifestations
*Santoro, G. Funct Neurol, 5:339-44, 1990.
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Migraine Prodrome
—  Mental status
changes
—  Irritable
—  Overactive
—  Neurological
symptoms
—  Yawning
—  Phonophobia
—  Dizziness
—  Tinnitus
—  General symptoms
—  Fatigue
—  Fluid retention
—  GI symptoms
—  Hunger
—  Nausea
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Definition of Migraine
Associated Dizziness
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Migrainous Vertigo
—  Definite
—  Episodic vertigo of moderate (or worse) severity
—  IHS migraine
—  1 or more of the following during 2 vertigo episodes:
—  Migrainous headache
—  Photo or phonophonobia
—  Visual or other aura
—  Other causes excluded
Neuhauser, et al. Neurology 2001;56:436–441
Migrainous Vertigo
—  Probable
—  Episodic vertigo of moderate (or worse) severity
—  At least 1 of the following:
—  IHS migrainous headache
—  Migrainous symptoms during vertigo
—  Migraine specific precipitants of vertigo
—  e.g. specific foods, sleep irregularities, hormonal
changes, response to antimigrainous drugs
—  Other causes excluded
Neuhauser, et al. Neurology 2001;56:436–441
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Migraine Associated Vertigo
—  Clues in clinical history:
—  Photophobia/Phonophobia
—  Visual aura
—  Precipitating factors: foods, sleep, hormonal
—  Headache does not need to be present
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Migraine & Vertigo: Prevalence
—  Migraine: 10% of U.S. pop*
—  Vertigo: 35% of U.S. migraine pop.**
—  Migraine + vertigo: ~ 3.5% of U.S. pop.
*Stewart et al, 1994
**Kayan/Hood, 1984; Selby/Lance, 1960
Kuritzky, et al, 1981
Prevalence: Migraine Vertigo &
Meniere s Disease
4.0%
3.5%
3.0%
2.5%
Prevalence in
2.0%
U.S. pop.
1.5%
1.0%
0.5%
0.0%
Migraine + vertigo*
Meniere's disease**
*Kayan/Hood, 1984; Selby/Lance, 1960
Kuritzky, et al, 1981
**Waserman et al., 1984
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Characteristics of Migraine
Dizziness
Dizziness in M.A.D.*
60%
50%
Occurence
in M.A.D.
40%
30%
20%
10%
0%
Vertigo
Non-vertigo
dizziness
Both
Type of dizziness in M.A.D.
*Johnson,
1998; Cutrer/Baloh, 1992
Replog/Goebel, 2002
Vertigo in M.A.D. (N = 396)*
30%
Occurence
25%
20%
15%
10%
5%
0%
seconds
minutes
hours
> 24 hrs
Duration of vertigo
*Cutrer/Baloh,
1992; Cass, et al 1997; Johnson, 1998;
Dieterich/Brandt, 1999; Neuhauser, et al, 2001.
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Pathophysiology of Migraine
Goadsby et al. 346 (4): 257-270, 2002
M.A.D.: Treatment
STEP 1. Diet modification/lifestyle changes
STEP 2. Prophylactic medication
STEP 3. Change/add prophylactic medication
STEP 4. Failure: neurological consultation
Diet and Migraine
—  Avoid
—  Aged cheeses (esp. blue cheese)
—  Processed meats
—  Red wine
—  Monosodium glutamate
—  Nutrasweet
—  Peanuts
—  Chocolate
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University
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Migraine Prophylaxis Medications
— Anticonvulsant (Topamax®)
— Calcium channel blockers (verapamil)
— Tricyclic antidepressants (nortriptyline,
amitriptyline)
— Beta blockers (atenolol, propranolol)
— Serotonin Reuptake Inhibitor (Effexor)
Comparison of M.A.D. and
Meniere s Disease
Symptoms
M.A.D.
Meniere’s
Disease
Vertigo
< and > 24 hrs
< 24 hrs
Hearing Loss
Uncommon
Always
Tinnitus
Photophobia
Unilat or Bilat Unilat or Bilat
May be
present
Never
M.A.D. : Summary
—  Headache history (past or FH)
—  Woman of reproductive age
—  Dizziness: many forms
—  Long-standing motion intolerance
—  Headache not required to diagnose M.A.D.
—  Treatment: Diet changes/prophylatic
medications
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Questions?:
Robert Battista, MD
630-789-3110
[email protected]
Thank You!
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Northwestern
University
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