H. Neuhauser

The interrelations of migraine, vertigo, and migrainous vertigo

Objective: To assess the prevalence of migrainous vertigo in patients with migraine and in patients with vertigo according to explicit diagnostic criteria that are presented for discussion. Methods: The authors prospectively evaluated 200 consecutive patients from a dizziness clinic and 200 patients from a migraine clinic for migrainous vertigo based on the following criteria: 1) recurrent vestibular symptoms (rotatory/positional vertigo, other illusory self or object motion, head motion intolerance); 2) migraine according to the criteria of the International Headache Society (IHS); 3) at least one of the following migrainous symptoms during at least two vertiginous attacks: migrainous headache, photophobia, phonophobia, visual or other auras; and 4) other causes ruled out by appropriate investigations. In addition, the authors compared the prevalence of migraine according to the IHS criteria in the dizziness clinic group with a sex- and age-matched control group of 200 orthopedic patients. Results: The prevalence of migraine according to the IHS criteria was higher in the dizziness clinic group (38%) compared with the age- and sex-matched control group (24%, p < 0.01). The prevalence of migrainous vertigo was 7% in the dizziness clinic group, and 9% in the migraine clinic group. In 15 of 33 patients with migrainous vertigo, vertigo was regularly associated with migrainous headache. In 16 patients, vertigo occurred both with and without headache, and in two patients headache and vertigo never occurred together. The duration of attacks varied from minutes to days. Conclusion: These results substantiate the epidemiologic association between migraine and vertigo and indicate that migrainous vertigo affects a significant proportion of patients both in dizziness and headache clinics.

Epidemiology of benign paroxysmal positional vertigo: a population based study

Objectives: To examine the prevalence and incidence, clinical presentation, societal impact and comorbid conditions of benign paroxysmal positional vertigo (BPPV) in the general population. Methods: Cross-sectional, nationally representative neurotological survey of the general adult population in Germany with a two stage sampling design: screening of 4869 participants from the German National Telephone Health Interview Survey 2003 (response rate 52%) for moderate or severe dizziness or vertigo, followed by validated neurotological interviews (n = 1003; response rate 87%). Diagnostic criteria for BPPV were at least five attacks of vestibular vertigo lasting <1 min without concomitant neurological symptoms and invariably provoked by typical changes in head position. In a concurrent validation study (n = 61) conducted in two specialised dizziness clinics, BPPV was detected by our telephone interview with a specificity of 92% and a sensitivity of 88% (positive predictive value 88%, negative predictive value 92%). Results: BPPV accounted for 8% of individuals with moderate or severe dizziness/vertigo. The lifetime prevalence of BPPV was 2.4%, the 1 year prevalence was 1.6% and the 1 year incidence was 0.6%. The median duration of an episode was 2 weeks. In 86% of affected individuals, BPPV led to medical consultation, interruption of daily activities or sick leave. In total, only 8% of affected participants received effective treatment. On multivariate analysis, age, migraine, hypertension, hyperlipidaemia and stroke were independently associated with BPPV. Conclusion: BPPV is a common vestibular disorder leading to significant morbidity, psychosocial impact and medical costs.

Epidemiology of vestibular vertigo A neurotologic survey of the general population

Objective: The purpose of this study was to determine the prevalence and incidence of vestibular vertigo in the general population and to describe its clinical characteristics and associated factors. Methods: The neurotologic survey had a two-stage general population sampling design: nationwide modified random digit dialing sampling for participation in the German National Telephone Health Interview Survey 2003 (response rate 52%) with screening of a random sample of 4,869 participants for moderate or severe dizziness or vertigo, followed by detailed neurotologic interviews developed through piloting and validation (n = 1,003, response rate 87%). Diagnostic criteria for vestibular vertigo were rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance. Vestibular vertigo was detected by our interview with a specificity of 94% and a sensitivity of 88% in a concurrent validation study using neurotology clinic diagnoses as an accepted standard (n = 61). Results: The lifetime prevalence of vestibular vertigo was 7.8%, the 1-year prevalence was 5.2%, and the incidence was 1.5%. In 80% of affected individuals, vertigo resulted in a medical consultation, interruption of daily activities, or sick leave. Female sex, age, lower educational level, and various comorbid conditions, including tinnitus, depression, and several cardiovascular diseases and risk factors, were associated with vestibular vertigo in the past year in univariate analysis. In multivariable analysis, only female sex, self-reported depression, tinnitus, hypertension, and dyslipidemia had an independent effect on vestibular vertigo. Conclusions: Vestibular vertigo is common in the general population, affecting more than 5% of adults in 1 year. The frequency and health care impact of vestibular symptoms at the population level have been underestimated.

Migraine and Ménière's disease: is there a link?

Background: A possible link between Ménière’s disease (MD) and migraine was originally suggested by Prosper Ménière. Subsequent studies of the prevalence of migraine in MD produced conflicting results. Objective: To determine the lifetime prevalence of migraine in patients with MD compared to sex- and age-matched controls. Methods: The authors studied 78 patients (40 women, 38 men; age range 29 to 81 years) with idiopathic unilateral or bilateral MD according to the criteria of the American Academy of Otolaryngology. Diagnosis of migraine with and without aura was made via telephone interviews according to the criteria of the International Headache Society. Additional information was obtained concerning the concurrence of vertigo and migrainous symptoms during Ménière attacks. The authors interviewed sex- and age-matched orthopedic patients (n = 78) as controls. Results: The lifetime prevalence of migraine with and without aura was higher in the MD group (56%) compared to controls (25%; p < 0.001). Forty-five percent of the patients with MD always experienced at least one migrainous symptom (migrainous headache, photophobia, aura symptoms) with Ménière attacks. Conclusions: The lifetime prevalence of migraine is increased in patients with MD when strict diagnostic criteria for both conditions are applied. The frequent occurrence of migrainous symptoms during Ménière attacks suggests a pathophysiologic link between the two diseases. Alternatively, because migraine itself is a frequent cause of audio-vestibular symptoms, current diagnostic criteria may not differentiate between MD and migrainous vertigo.

Migrainous vertigo Prevalence and impact on quality of life

Objective: To investigate the epidemiology of migrainous vertigo (MV) in the general population by assessing prevalence, clinical features, comorbid conditions, quality of life, and health care utilization. Methods: We screened a representative sample of the adult population in Germany (n = 4,869) for moderate or severe dizziness/vertigo and followed up with validated neurotologic telephone interviews (n = 1,003). Diagnostic criteria for MV were as follows: 1) recurrent vestibular vertigo; 2) migraine according to the International Headache Society; 3) migrainous symptoms during at least two vertiginous attacks (migrainous headache, photophobia, phonophobia, or aura symptoms); and 4) vertigo not attributed to another disorder. In a concurrent validation study (n = 61) the interviews had a sensitivity of 84% and a specificity of 94% for vestibular vertigo and 81% and 100% for migraine. Results: The lifetime prevalence of MV was 0.98% (95% CI 0.70 to 1.37), the 12-month prevalence 0.89% (95% CI 0.62 to 1.27). Spontaneous rotational vertigo was reported by 67% of participants with MV while 24% had positional vertigo. Twenty-four percent always experienced headaches with their vertigo. Logistic regression analysis comparing participants with MV with dizziness-free migraineurs showed an independent association with coronary heart disease but not with sex, age, migrainous aura, education, stroke, hypertension, hyperlipidemia, body mass index, or depression. Age-adjusted health-related quality of life scores (SF-8 Health Survey) were consistently lower in participants with MV compared to dizziness-free controls. Two thirds of participants with MV had consulted a doctor but only 20% of these were diagnosed with MV. Conclusions: Migrainous vertigo is relatively common but underdiagnosed in the general population and has considerable personal and healthcare impact.

Epidemiology of vertigo, migraine and vestibular migraine

Both migraine and vertigo are common in the general population with lifetime prevalences of about 16 % for migraine and 7 % for vertigo. Therefore, a concurrence of the two conditions can be expected in about 1.1 % of the general population by chance alone. However, recent epidemiological evidence suggests that the actual comorbidity is higher, namely 3.2 %. This can be explained by the fact that several dizziness and vertigo syndromes occur more frequently in migraineurs than in controls including benign paroxysmal positional vertigo, Meniere’s disease, motion sickness, cerebellar disorders and anxiety syndromes which may present with dizziness. In addition, there is increasing recognition of a syndrome called vestibular migraine (VM), which is vertigo directly caused by migraine. VM affects more than 1 % of the general population, about 10 % of patients in dizziness clinics and at least 9 % of patients in migraine clinics.Clinically, VM presents with attacks of spontaneous or positional vertigo lasting seconds to days. Migrainous accompaniments such as headache, phonophobia, photophobia or auras are common but not mandatory. Cochlear symptoms may be associated but are mostly mild and non-progressive. During acute attacks one may find central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval, vestibular testing adds little to the diagnosis as findings are mostly minor and non-specific. In the absence of controlled studies, treatment of VM is adopted from the migraine sphere comprising avoidance of triggers, stress management as well as pharmacotherapy for acute attacks and prophylaxis.

Self-treatment of benign paroxysmal positional vertigo: Semont maneuver vs Epley procedure

The authors compared the efficacy of a self-applied modified Semont maneuver (MSM) with self-treatment with a modified Epley procedure (MEP) in 70 patients with posterior canal benign paroxysmal positional vertigo. The response rate after 1 week, defined as absence of positional vertigo and torsional/upbeating nystagmus on positional testing, was 95% in the MEP group (n = 37) vs 58% in the MSM group (n = 33; p < 0.001). Treatment failure was related to incorrect performance of the maneuver in the MSM group, whereas treatment-related side effects did not differ significantly between the groups.

Zolmitriptan for treatment of migrainous vertigo: A pilot randomized placebo-controlled trial

Migrainous vertigo (MV) is a frequent vestibular syndrome, but current evidence for both acute1-3⇓⇓ and prophylactic1,3,4⇓⇓ treatment consists only of a few uncontrolled case reports on the successful use of migraine medication. Vestibular suppressants such as promethazine, dimenhydrinate, and meclizine often reduce but do not abort vertigo and have sedating side effects. There is anecdotal evidence that sumatriptan may be effective.2,5⇓ To evaluate the effect of an oral triptan on acute MV we chose zolmitriptan, which is less hydrophilic than sumatriptan, thus facilitating CNS penetration. This study was a randomized, double-blind, placebo-controlled, crossover-after-one-attack trial of 2.5 mg oral zolmitriptan for treatment of acute migrainous vertigo. Criteria6 for MV were (1) episodic vestibular symptoms of at least moderate severity (rotational vertigo, other illusory self or object motion, positional vertigo or head motion intolerance, i.e., sensation of imbalance or illusory motion provoked by head movements). Vestibular symptoms were “moderate” if they interfered with but did not prohibit daily activities, “severe” if patients could not continue daily activities; (2) current or …

Short-term efficacy of Epley’s manoeuvre: a double-blind randomised trial

Background: Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common vestibular disorder and can be easily treated with Epley’s manoeuvre. Thus far, the short-term efficacy of Epley’s manoeuvre for treatment of PC-BPPV is unknown. Objectives: To evaluate the efficacy of Epley’s manoeuvre for treatment of PC-BPPV 24 h after applying the manoeuvre. Methods: The short-term efficacy of Epley’s manoeuvre was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomised study design. Results: 24 h after treatment, 28 of 35 (80%) patients in the Epley’s manoeuvre group had neither vertigo nor nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001). Conclusion: Epley’s manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.

A modified Epley’s procedure for self-treatment of benign paroxysmal positional vertigo

Article abstract We compared the efficacy of a modified Epley’s procedure (MEP) and Brandt-Daroff exercises (BDE) for self-treatment of benign paroxysmal positional vertigo of the posterior semicircular canal (PC-BPPV) in 54 patients. PC-BPPV resolved within 1 week in 18 of 28 patients (64%) using the MEP and in 6 of 26 patients (23%) performing BDE (p < 0.01). Type and adequate performance of the maneuver predicted treatment outcome in the multivariate analysis. The frequency of side effects was not significantly different between the two groups. The MEP is more suitable for self-treatment of PC-BPPV than conventional BDE.