Louisa Murdin

Vertigo as a migraine trigger

Background: It is reported in some individual patients that vestibular stimuli can trigger migraine attacks. This study used a case-control design to examine systematically the hypothesis that vertigo induced by vestibular stimulation (rotation/caloric testing) can act as a specific migraine trigger. Methods: A total of 123 new patients attending neuro-otology or neurology clinics were studied with questionnaires and physician interview to ascertain migraine history according to International Headache Society criteria. A total of 79 who underwent rotation/caloric vestibular testing (test group) were compared with 44 control patients in whom no such testing was carried out (control group). The principal outcome measure was the occurrence of a migraine attack within 24 hours of exposure to vestibular stimulation. Results: Of those participants with a past history of migraines, 19/39 (49%) of the test group experienced a migraine in the study time window, compared with 1/21 (5%) of the control group. Binary logistic regression analysis confirmed that vestibular testing was associated (p < 0.05) with migraine attacks. Conclusions: The results indicate that induced vertigo can act as a migraine trigger, a finding with implications for the diagnosis of patients with episodic vertigo and migraine headache. While such patients may well have basilar migraine or migrainous vertigo, alternatively, another disorder causing episodic vertigo (e.g., benign paroxysmal positional vertigo or Ménière disease) may be triggering migraine headaches.

Epidemiology of balance symptoms and disorders in the community: a systematic review.

Introduction Balance disorders presenting with symptoms of dizziness or vertigo may have significant impact on quality of life and are a recognized risk factor for falls. Objective The objective of this review was to systematically synthesize the published literature on the epidemiology of balance symptoms and disorders in the adult community population. Methods A search was carried out across PubMed, Medline, and Cochrane databases to identify suitable studies. Studies were eligible for inclusion if they contained data on the epidemiology of symptoms of balance disorders (dizziness and vertigo) or balance disorders sampled from community-based adult populations. Data were collected on prevalence and incidence of balance symptoms and on specific balance disorders. A validated risk-of-bias assessment was carried out. Results Twenty eligible studies were identified. The lifetime prevalence estimates of significant dizziness ranged between 17 and 30%, and for vertigo between 3 and 10%. Published point prevalence data exist for Ménière’s disease (0.12–0.5%) and for vestibular migraine (0.98%). For benign paroxysmal positional vertigo, 1-year incidence estimates range from 0.06 to 0.6%. There are no community-based studies on the prevalence or incidence of chronic uncompensated peripheral vestibular disorders or vestibular neuritis. Conclusion Symptoms of dizziness and vertigo are common in the adult population, and data give a coherent picture of community epidemiology. These data can inform rational service planning and much-needed clinical trials in this field. There are insufficient data on specific balance disorders, especially peripheral vestibular disorders such as vestibular neuritis and its long-term sequelae.

Managing motion sickness

#### Summary points Motion sickness is a syndrome of nausea and vomiting, pallor, sweating, headache, dizziness, malaise, increased salivation, apathy, drowsiness, belching, hyperventilation, and stomach awareness. Symptoms can be provoked by externally imposed motion, or implied self motion from a moving visual field, such as in a cinema. The condition has been recognised from the early days of sea travel and the word for sickness, “nausea,” derives from the Greek word νανς, meaning “ship.” Travel by car, train, or other transport is part of everyday life for most people, and motion sickness is a common problem. Estimating its prevalence is complex because reported symptoms depend on variables such as previous avoidance and exposure, as well as presumed inherent susceptibility. Some estimates are presented in table 1⇓. Motion sickness may have an important effect on occupational activity for some people, such as airline pilots, those in the armed forces, and emergency services staff. General practitioners may frequently encounter patients who report difficulties in work or daily life related to motion sickness, or those seeking advice about prevention before a forthcoming journey. We review the management …

Motion sickness in migraine and vestibular disorders

Motion sickness is a syndrome provoked by sensory conflict that involves the vestibular system with symptoms resembling those of common neuro-otological disorders including vestibular neuritis (VN) and vestibular migraine (VM). By contrast, it is generally believed that bilateral vestibular failure (BVF) causes reduced motion sickness susceptibility. We investigate differences between these conditions with a single protocol using validated objective experimental (off-vertical axis rotation, OVAR1) and validated patient-centred measures of motion sickness susceptibility.2 Five groups were studied: 1. Normal healthy controls ( n=12; mean age 51, SD 17.2; 4/12 women). 2. VN (history of acute vertigo without neurological features or hearing loss; none treated with steroids acutely; positive head thrust test; spontaneous unidirectional horizontal nystagmus; acute caloric canal paresis >30%, mean canal paresis repeated in chronic phase after 6 weeks was 38% (SD 31); n=12; disease duration range 10–33 months; mean age 45, SD 15.3; 5/12 women). 3. BVF (absent caloric or rotational responses; confirmed in chronic phase; n=8; mean age 51, SD 11.5; 3/8 women). 4. VM (recurrent episodic vestibular symptoms in association with migraine according to published criteria with no vestibular test abnormalities3; n=12; mean age 45, SD 15.3; 11/12 women). 5. Migraine without vestibular symptoms ( M ; recurrent headaches meeting International Headache Society (IHS) 2004 criteria; with/without aura but with no significant vestibular symptoms3; n=12; mean age 41, SD 13.6; 8/12 women. Two groups of patient with migraine were studied (one with vestibular symptoms, VM, and one without vestibular symptoms, M) to determine whether the presence of vestibular symptoms in the setting of migraine influences motion sickness susceptibility. The normal controls and the migraine group were screened for vestibular symptoms but did not undergo formal vestibular testing. Participants were …

Sensory Dysmodulation in Vestibular Migraine: An Otoacoustic Emission Suppression Study

To seek evidence of sensory dysmodulation in auditory brainstem reflexes in patients with vestibular migraine by studying suppression of otoacoustic emissions (OAEs) by contralateral noise.

Head deviation in progressive supranuclear palsy: enhanced vestibulo-collic reflex or loss of resetting head movements?

It is unclear how the torticollis occasionally observed in patients with progressive supranuclear palsy (PSP) relates to vestibulo-collic reflex mechanisms. We report here the results of vestibular evoked myogenic potentials (VEMPs) in a PSP patient with forced head deviation in the opposite direction of turning, leading to torticollis for a few seconds. As VEMPs were normal bilaterally we conclude that an enhanced vestibulo-collic reflex per se is not the cause of the torticollis in our patient. The abnormal head deviation induced by turning in some PSP patients is best explained by damage to reticular nuclei responsible for resetting eye and head saccades. When such mechanisms are defective, unopposed vestibulo-collic reflexes can lead to eye and head deviations in the opposite direction of body turns.

Otoacoustic emission suppression testing: A clinician's window onto the auditory efferent pathway

There has been considerable progress in the last decade in understanding the role of the auditory efferent pathway. This is exemplified by the development of tests for the suppressive effect of contralateral noise on the production of otoacoustic emissions by the outer hair cells of the cochlea. Suppression of OAEs is demonstrably subserved by the auditory efferent pathway, as carried in the inferior vestibular nerve. Advances in the development of testing the suppressive effects of noise have been paralleled by application to a variety of relevant clinical scenarios, enhancing and refining the use of this test in routine clinical practice. In particular, OAE suppression testing has been proposed in the assessment of cerebello-pontine angle tumours, multiple sclerosis, myasthenia gravis, auditory neuropathy/dys-synchrony and auditory processing disorders. This review considers these advances, along with practical issues and pitfalls in testing. OAE suppression testing is the most widely accessible method of testing auditory efferent function in the clinic, but consensus has yet to be achieved as to a standard protocol, and interpretation of this test, and elements of the underlying physiology remain incompletely understood. It is a useful addition to the audiological test battery, allowing the clinician a window onto the auditory efferent pathway.

Balance, falls risk, and related disability in untreated vestibular schwannoma patients

Background Many vestibular schwannoma (VS) patients complain of balance dysfunction; however, validated standardized assessments are lacking. The relative contribution of imbalance and factors like anxiety to disability is unknown. Because imbalance significantly affects quality of life in this group and vestibular rehabilitation may improve outcomes, determining the severity of balance dysfunction is important to understand long-term rehabilitation needs. Aim To assess functional balance (Vertigo Symptom Scale-Vertigo [VSS-VER] and Functional Gait Assessment [FGA]) and the relative contribution of symptom severity (VSS-VER), ambulant posture (FGA), and anxiety symptoms (Vertigo Symptom Scale-Anxiety [VSS-SA]) to disability in untreated patients. Methods Patients not exposed to surgery completed the VSS, Vertigo Handicap Questionnaire (VHQ), and FGA. VSS scores were compared with migrainous vertigo (MV) patients, a mixed neuro-otological group, and healthy controls. Results A correlation was found between decreased FGA and increasing age (r = - 0.35; p < 0.01), female sex (r = 0.42; p = 0.001), increasing handicap (r = - 0.55; p < 0.001), and symptom severity (r = - 0.52; p < 0.001). In 12 of 21 patients (57%) > 60 years of age the FGA score was ≤ 22 suggesting increased falls risk. VSS-VER scores were higher than in healthy controls (p < 0.001) but lower than MV (p < 0.001) and mixed neuro-otology controls (p < 0.001). VSS-SA scores in VS patients with balance symptoms were higher than normal controls (p < 0.05) and correlated with handicap (r = 0.59; p < 0.001) and symptom severity (r = 0.74; p < 0.001). After controlling for age and sex, the VSS-VER, VSS-SA, and FGA explained 47% of the variation in VHQ scores. Conclusion Older VS patients are at significant risk of falls. Balance symptoms are more severe than in healthy controls but less than other neuro-otological patients. Balance symptom severity, anxiety symptoms, and ambulant posture were significant contributors to disability and should be the focus of vestibular rehabilitation strategies.

Restriction of salt intake and other dietary modifications for the treatment of Ménière's disease or syndrome

This is the protocol for a review and there is no abstract. The objectives are as follows: To determine the effectiveness of dietary modifications, specifically restriction of salt, alcohol and caffeine intake, in patients suffering from Ménière’s disease or syndrome. We will also review other dietary modifications but we will limit analysis of these studies to a narrative review.

Motion sickness in migraine and vestibular disorders: Figure 1

Motion sickness is a syndrome provoked by sensory conflict that involves the vestibular system with symptoms resembling those of common neuro-otological disorders including vestibular neuritis (VN) and vestibular migraine (VM). By contrast, it is generally believed that bilateral vestibular failure (BVF) causes reduced motion sickness susceptibility. We investigate differences between these conditions with a single protocol using validated objective experimental (off-vertical axis rotation, OVAR1) and validated patient-centred measures of motion sickness susceptibility.2 Five groups were studied: 1. Normal healthy controls ( n=12; mean age 51, SD 17.2; 4/12 women). 2. VN (history of acute vertigo without neurological features or hearing loss; none treated with steroids acutely; positive head thrust test; spontaneous unidirectional horizontal nystagmus; acute caloric canal paresis >30%, mean canal paresis repeated in chronic phase after 6 weeks was 38% (SD 31); n=12; disease duration range 10–33 months; mean age 45, SD 15.3; 5/12 women). 3. BVF (absent caloric or rotational responses; confirmed in chronic phase; n=8; mean age 51, SD 11.5; 3/8 women). 4. VM (recurrent episodic vestibular symptoms in association with migraine according to published criteria with no vestibular test abnormalities3; n=12; mean age 45, SD 15.3; 11/12 women). 5. Migraine without vestibular symptoms ( M ; recurrent headaches meeting International Headache Society (IHS) 2004 criteria; with/without aura but with no significant vestibular symptoms3; n=12; mean age 41, SD 13.6; 8/12 women. Two groups of patient with migraine were studied (one with vestibular symptoms, VM, and one without vestibular symptoms, M) to determine whether the presence of vestibular symptoms in the setting of migraine influences motion sickness susceptibility. The normal controls and the migraine group were screened for vestibular symptoms but did not undergo formal vestibular testing. Participants were …