Vertigo and Dizziness Often Complicate Migraine Evaluation

BY CHARLES BANKHEAD
Contributing Writer

ORLANDO, FLA. -(ECCC) Vertigo and dizziness frequently complicate the evaluation and management of migraine, said Dr. Jan Lewis Brandes on July 18 at a headache symposium presented by the Diamond Headache Clinic Research and Educational Foundation.

"Clinical evidence increasingly suggests that recurrent vertigo may be part of a migraine attack and that a careful history identifying vestibular and nonvestibular symptoms from infancy to adulthood will aid in accurate diagnosis," said Dr. Brandes, assistant clinical professor of neurology at Vanderbilt University School of Medicine in Nashville.

In evaluating the migraineur, one of the first diagnostic essentials is to determine whether dizziness or vertigo is related to the migraine. Physicians might find it helpful to separate an association between migraine and vertigo into three categories:

• Migrainous vertigo or vertigo that is causally related to the migraine
• Vertigo syndromes that are not part of the migraine constellation but that are statistically associated with headache
• Vertigo that coexists with migraine simply by chance

Authorities disagree as to whether vertigo and dizziness are migraine-associated vestibular symptoms that warrant special attention or symptoms that represent a type of aura. In one study of patients with migrainous vertigo, half the patients had vertigo only during the headache phase of migraine. In the remaining patients, vertigo occurred with and without headache. In only two patients did headache and vertigo never occur simultaneously (Cephalalgia 2004;24:83-91).

Migraine and dizziness both affect a substantial proportion of the general population, further complicating the evaluation process, said Dr. Brandes. Between 15% and 17% of women and 5% and 8% of men have migraine, and the overall prevalence of dizziness is more than 20%.

The diagnostic workup should clearly distinguish between vertigo and dizziness. Importantly, the former is a vestibular symptom and the latter is a nonvestibular symptom. Patients typically describe vertigo as a rotating or spinning sensation or some other type of motion. Dizziness might be described as lightheadedness, unsteadiness, swimmy-headedness, drowsiness, or near faint, said Dr. Brandes.

A thorough history is crucial to the diagnosis of a patient presenting with migrainous vertigo. Patients should be asked about their tolerance for head motion, with the understanding that migrainous vertigo and dizziness can coexist. Duration of vertigo can range from a few seconds to hours, and episodes lasting several days have been reported.

Similar to other features of aura, vertigo can precede headache, begin with headache, or occur well into the headache phase. In some cases, patients have photophobia, phonophobia, and visual or sensory auras, in addition to vertigo.

"The clinical presentation of migrainous vertigo can vary considerably," said Dr. Brandes. "It is the consistent and repeated presence of migrainous features along with the vertigo that lead the clinician to an accurate diagnosis.

Physical examination of the patient with migraine and vertigo often yields only nonspecific findings. As a consequence, diagnostic accuracy rests heavily on a thorough patient history.

The differential diagnosis of migrainous vertigo must include common causes of recurrent vertigo. Examples include vertigo secondary to infection, autoimmune inner ear disease, vestibular neuritis, multiple sclerosis, and early-stage Meniere's disease.

Dizziness is a prominent side effect of many medications, including those used to treat migraine, which mandates a thorough investigation of a patient's current medication usage and any associations with the onset of dizziness or vertigo.

Copyright 2007 Elsevier Custom Conference Coverage. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the copyright owner. No responsibility is assumed by the Publisher for any injury and/or damage to persons or property as a matter of products liability, through negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein. Because of rapid advances in the medical sciences, the Publisher recommends that independent verification of diagnoses and drug dosages should be made. Opinions expressed in this publication are those of the original authors and do not necessarily reflect those of the Publisher, the sponsor, or the editors. Elsevier assumes no liability for any material published herein.