Multidisciplinary Experts Consensus for Assessment and Management of Vestibular Migraine
Vestibular migraine (VM) is a common disorder characterized by recurrent episodes of dizziness or vertigo, often accompanied by symptoms such as nausea, vomiting, and headaches. Despite its prevalence, VM is frequently misdiagnosed as other conditions such as posterior circulation ischemia (PCI), transient ischemic attack (TIA), peripheral vestibular vertigo, Meniere’s disease (MD), or multiple cerebral infarctions. The misdiagnosis rate can be as high as 80%, highlighting the need for a standardized approach to its assessment and management. This consensus aims to provide a comprehensive framework for the diagnosis and treatment of VM, based on the latest research and expert opinions.
Development of the Concept of Vestibular Migraine
The concept of VM has evolved significantly over the past century. Initially proposed in 1917 by Boemhei, the relationship between migraine and vertigo was further described by Kayan and Hood in 1984. Over the years, VM has been referred to by various terms such as migraine-associated vertigo, migraine-related vestibulopathy, and migrainous vertigo, leading to confusion in its diagnosis and management. It was not until 2001 that Neuhauser et al. proposed a set of diagnostic criteria for VM, which were more liberal than those in the International Classification of Headache Disorders (ICHD). These criteria were later refined and adopted by the Barany Society and the International Headache Society (IHS) in 2012, and subsequently included in the ICHD-IIIb in 2013 and ICHD-III in 2018. Despite these advancements, the diagnostic rate of VM remains low, with about 14.5% of neurologists and 19% of ENT doctors never diagnosing the condition.
Epidemiology of Vestibular Migraine
VM is one of the most common causes of recurrent vertigo, with a prevalence estimated at 1% in the general population. It can affect individuals of any age, but there is a clear female predominance, with a male-to-female ratio of 1:1.5–5. The annual incidence of VM in women aged 40–54 years is around 5%. Before the publication of the ICHD-IIIb criteria, VM accounted for 4.2% to 29.3% of cases in ENT outpatient services, 6% to 25.1% in vertigo clinics, and 9% to 11.9% in headache clinics. Following the release of the diagnostic criteria, a 2016 prospective multicenter study found that VM and possible VM accounted for 10.3% and 2.5% of patients with migraine headaches, respectively. The disorder is particularly prevalent in China, where it is the second most common cause of vertigo after benign paroxysmal positional vertigo (BPPV).
Pathogenesis of Vestibular Migraine
The exact pathogenesis of VM remains unclear, but several hypotheses have been proposed. These include cortical spreading depression, neurotransmitter abnormalities, trigeminal nerve-vessel dysfunction, ion channel insufficiencies, central signal integrating abnormalities, and genetic factors. Familial aggregation has been observed in clinical practice, suggesting a genetic component to the disorder. Some studies have found that VM can follow an autosomal dominant inheritance pattern, with lower penetrance in males than in females. Hormonal factors, particularly the decline in sex hormones during menopause, may also play a role in the transformation of migraine headaches into VM in some female patients.
Symptoms, Signs, and Work-ups for Vestibular Migraine
VM can present at any age, with symptoms varying widely among patients. The initial symptom may be either headache or vertigo, and the two may occur simultaneously or sequentially. In most cases, headache precedes vertigo by several years, but in some patients, vertigo may occur before headache or even in the absence of headache. Stress, fatigue, anxiety, lack of sleep, excessive physical activity, and certain foods can trigger VM attacks. The clinical manifestations of VM are diverse, with patients often presenting differently at different ages or during different attacks. Common symptoms include vertigo, dizziness, nausea, vomiting, and unsteady gait. Some patients may also experience head movement intolerance, neck discomfort, mood disorders, and transient hearing loss during attacks.
During an attack, transient signs such as body imbalance, nystagmus, and visual field deficits may occur. However, these signs are not specific to VM and can be difficult to distinguish from those of peripheral or central vestibular disorders. Vestibular function tests, such as caloric testing and video-head-impulse testing, can help identify abnormalities in vestibular function. MRI findings in VM patients may show multiple white matter hyperintense foci in subcortical white matter and centrum ovale, but these findings are non-specific and primarily useful for differential diagnosis.
Diagnosis and Differential Diagnosis of Vestibular Migraine
The diagnosis of VM is based on the presence of five or more episodes of moderate to severe vestibular symptoms, with or without headache. The diagnostic criteria emphasize the recurrent nature of the attacks. A detailed history, including family history of migraine, is crucial for accurate diagnosis. The differential diagnosis of VM includes several other conditions that cause recurrent vertigo, such as BPPV, MD, PCI, and non-structural dizziness disorders.
BPPV is the most common cause of recurrent vertigo and is diagnosed using positional tests such as the Dix-Hallpike and supine roll tests. MD is characterized by episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness, and is diagnosed based on clinical history and physical examination. PCI, which includes infarction and TIA, is a life-threatening condition that requires urgent evaluation with neuroimaging. Non-structural dizziness disorders, such as functional and psychiatric dizziness, are characterized by persistent dizziness that fluctuates with mood and is exacerbated by stress.
Management of Vestibular Migraine
The management of VM involves both symptomatic treatment during acute attacks and preventive measures to reduce the frequency and severity of episodes. Acute treatment focuses on controlling symptoms such as vertigo and nausea, using medications such as triptans and vestibular inhibitors. Preventive treatment is recommended for patients with frequent or severe attacks and follows the same principles as migraine headache management. Options include beta-blockers (e.g., propranolol, metoprolol), calcium channel antagonists, antiepileptics (e.g., valproic acid, topiramate), and other medications such as Gastrodin and Nicergoline. Vestibular rehabilitation and patient education are also important components of VM management, particularly for patients with comorbid anxiety and depression.
Traditional Chinese medicine (TCM) offers an alternative approach to VM treatment, focusing on syndrome differentiation and the management of both symptoms and underlying causes. Studies have shown that Tianshu capsule, a TCM formulation, can be effective in reducing the frequency and severity of VM attacks.
Conclusion
Vestibular migraine is a common but often misdiagnosed condition that requires a multidisciplinary approach for accurate diagnosis and effective management. The development of standardized diagnostic criteria has improved the recognition of VM, but further research is needed to fully understand its pathogenesis and optimize treatment strategies. This consensus provides a comprehensive framework for the assessment and management of VM, emphasizing the importance of a detailed clinical history, appropriate diagnostic work-ups, and a tailored treatment plan that addresses both acute symptoms and long-term prevention.
doi.org/10.1097/CM9.0000000000000064
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