This post is an overview of notes taken from the talk given by Dr Michael Teixido on 'Understanding Balance, Vertigo and Dizziness' at the Migraine World Summit, March 2019.
In the notes below, vestibular migraine is referred to as VM.
Jump to:
- Understanding Balance, Vertigo and Dizziness
- How is vestibular migraine diagnosed?
- What are the symptoms of vestibular migraine?
- How is vestibular migraine the same or different to migraine associated vertigo (MAV)?
- Are there causes of vestibular migraine beyond genetic disposition?
- Migraine triggers
- The debilitating nature of VM
- Is VM often mis-diagnosed?
- Treatments for VM
- Is physical therapy useful?
- What can a chronic VM patient expect from their doctor?
- How do you approach with someone who has tried and failed many treatments?
- How can a patient develop better coping skills in relation to isolation, and symptoms leading to people being house-bound?
- Which expert should a patient be working with?
- CGRP treatments
- Any new treatments?
- 💬 Comments
Understanding Balance, Vertigo and Dizziness
Dr Michael Teixido (otolaryngologist)
Migraine involves all parts of the brain, and the pathways that control our balance are part of the brain that can be affected. We have tiny organs, that work in pairs, so that when we turn our head and body we do not lose our position in space. If this is distorted in any way, then we can lose our sense of orientation or have a sense of spinning or being displaced.
About 25% of migraneurs experience a sense of dizziness at some time, making it a common cause of dizziness. In the US, 2.7% of persons experience vestibular migraine.
Some people are more susceptible to VM due to their genetics. The genetic imprint can even be different among migraneurs in the family, and so the same family members experience different forms of migraines. You can have migraine without even having a headache.
How is vestibular migraine diagnosed?
There isn’t a specific test for vestibular migraine. It is recognised through clinic suspicion, and a classic migraine pattern of disease. A typical patient would come with a new onset of dizziness and may have an increase in headache activity. They may come with vestibular episodes. Some of these symptoms may come on in response to migraine triggers such as stress, fatigue, weather changes.
What are the symptoms of vestibular migraine?
A patient with vestibular migraine can have almost any kind of vestibular symptom – spinning, light-headedness, sense of disorientation in space (the ‘Alice in Wonderland’ symptom). There can be a rocking sensation – this is a red flag for a clinician.
How is vestibular migraine the same or different to migraine associated vertigo (MAV)?
MAV was a term used by neurologists in Germany who first described the association between migraine and vertigo symptoms. Their criteria was rather loose, and not strict enough for studies. After this, the International Headache Society coined the term vestibular migraine, with more strict diagnostic criteria, to be used to study the problem of vestibular migraine. It doesn’t make a difference to patients which term is used, as treatment is the same.
Are there causes of vestibular migraine beyond genetic disposition?
They aren’t contagious! Most people with VM have a memory of being sick in the backseat of a car as a child due to an extraordinary sensitivity to tilting. VM patients are more sensitive than ‘normal’ people and can sense very small tilts. They can even be intolerant of motion of their own heads.
Migraine triggers
Fatigue can cause an increase in vestibular attacks, also days when the weather has changed. Also stress is a trigger, as well as foods. Triggers for VM are the same as migraine in general.
The debilitating nature of VM
Vestibular symptoms can be more debilitating than the pain itself. There is a conception that migraine is head pain, on one side associate with an intolerance of light and sound. But migraine takes many forms. Many patients have learnt to bear through symptoms, but dizziness is more debilitating and so a new onset means they find increased difficulties.
Young patients tend to have ‘classic headaches’ that become less severe over time. Later in life, secondary symptoms take centre stage, including dizziness. So a person who thought their migraine went away, may come to the doctor with new onset dizziness and a mild headache.
Is VM often mis-diagnosed?
Yes, very often. It is very easy for VM to be confused with other vestibular disorders such as BBPV – caused by loose crystals in the inner ear. Patients with VM will often answer yes to questions that point towards loose crystals such as being sensitive to head motion. This explains the problem of mis-diagnosis in part. Symptoms of VM can last just a few seconds to days or months, but those with brief episodes can be mis-diagnosed with BBPV. About 22% of people with VM do have loose crystals, which also complicates diagnosis.
What other common mis-diagnoses are there? Menieres disease is one. It is characterised by a fluid in-balance in the ears. Patients with this condition have a specific sense of which ear is implicated due to symptoms. Some patients may have a little of both conditions. Their inner ear may be injured by the migraine and turns into Menieres disease.
Treatments for VM
In contrast to migraine headache we don’t have good treatments at the time of an attack. The best strategy is preventative medication. Most patients have frequent episodes, often every day. This is chronic migraine so needs to be treated with preventatives. The same medications are used to treat migraine headache. In VM we can add on the sodium channel blockers, calcium channel blockers, beta-blockers and serotonin drugs. Some patients will require anti-anxiety medications, especially those with the rocking sensation as the symptoms can cause anxiety.
There are no devices or procedures.
Reduction of triggers is important. It takes a concerted effort for wellness and growth.
Stress reduction is important. Also the reduction of triggers in the diet to stabilise the brain. We have a personal threshold for migraine and so need to increase the threshold so there is more room for triggers to add up without going over the threshold. Easiest group of triggers to reduce is food triggers e.g. processed foods. Eat mostly plants.
Lifestyle measures are often under-rated and take a lot of time and effort on the part of the doctor and patient.
Is physical therapy useful?
Yes, but with caution. It can be good for re-aligning any in-balances in the balance system. It can be helpful for identifying and eliminating loose crystals.
But therapists without sufficient knowledge can overwork their VM patients. They must not be overworked as it can be a step backwards. So a good therapist will assess the patient. A ‘dose’ of therapy may only be minutes if that it is what is appropriate to the patient. It is also useful for patients to have support, and be in contact with someone who can tell them that improvement can happen.
Are there any contra-indications? Yes, overdoing movement. You can’t ‘bear through’ the pain.
What can a chronic VM patient expect from their doctor?
You need to become a partner in your treatment. The doctor is the coach and tells the patient the work to do, but the patient needs to do the work. A diary is useful for noting the efficacy of medications and other treatments, as well as causes or triggers.
How do you approach with someone who has tried and failed many treatments?
The majority of patients will improve.
- look at diet (such as reducing caffeine)
- reduce triggers
- try other medication drugs, or re-try drugs already tried within the same category
How can a patient develop better coping skills in relation to isolation, and symptoms leading to people being house-bound?
There can be real despair and grieving which is a physiological and psychic stress. CBT is a good option as it looks at how the patient is thinking about their symptoms. It has good evidence for the treatment of migraine. Look for the ‘Feeling Good Handbook’.
Which expert should a patient be working with?
Those with training in ear medicine (oto-neurologists) and ear neurology (neuro-otologists).
CGRP treatments
We don’t yet know whether CGRP is involved in vestibular symptoms. However, it is often the case that vestibular symptoms often reduce once head pain is more under control.
Any new treatments?
The biggest thing that is going to happen is that more individuals will become aware that the diagnosis exists and ENT doctors are becoming aware of the greater commonality of VM. It is more common than Menieres disease.
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Please follow the advice of your doctor as to all medical treatments, supplements, and dietary choices, as set out in my disclaimer. I am not a medical professional, and this is simply my story and the resources that are helpful to me.
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