Vestibular Migraine

Migraine is a genetically induced hypersensitivity to internal or external stimuli within central nervous system neurons (1). When a neuron that is primed to a migraine, and is triggered by a stimulus either inside or outside of your body, the neuron reacts through a migraine (1). There are treatments for both acute and chronic migraines episodes as well as prevention methods an individual can use to reduce the number of migraines that occur. Migraine is generally considered a headache, however not everyone with migraines experience headaches. Some people get migraines in the form of vertigo, called Vestibular Migraine or Migraine Associated Vertigo. It is estimated that about 1% of the population has Vestibular Migraines (2). Vestibular Migraine often goes undiagnosed or misdiagnosed for a while before an individual receives a diagnosis of Vestibular Migraine. Some of the symptom and diagnosis criteria will be helpful to pinpoint exactly what’s going on for you specifically. Once you or a loved one is diagnosed with Vestibular Migraines, there are many ways that they can be treated. There is not a quick fix formula for Vestibular Migraine, and finding what works for you may be a process. 

Symptoms & Diagnosis

There are many symptoms of Vestibular Migraine and it can present differently in each individual. Using your symptom history and some objective tests to rule out other vestibular disorders, your clinician should be able to come to the diagnosis of Vestibular Migraine if it is right for you. It is important to recognize and remember that many vestibular disorders present similarly, and that migraine could present one way in you, and another in someone else. Logging your symptoms before and during your treatment is a good way to work with your healthcare team toward the right diagnosis. The symptoms include, but are not limited to:

• Severe head pain
• Vertigo with or without head pain
• Photophobia
• Phonosensitivity
• Motion sensitivity 
• Neck pain/cervicalgia
• Imbalance
• Spatial disorientation
• Panic and anxiety
• Altered cognition
• Many others depending on the person
• Lightheadedness
• Feeling foggy or off
• Increased symptoms with multi step tasks
• Tinnitus

The symptoms listed above are not the only symptoms patients experience, and you do not need to have headaches to be diagnosed with Vestibular Migraines. Because there are so many ways you can feel dizzy, and sometimes it can be hard to describe to the doctor, I recommend starting a list and showing it to your provider when you have your appointment. This can help you and your healthcare team decide if this is the diagnosis for you.

After a thorouogh history taking, likely from a few practitioners, you will undergo a series of tests. These will differ depending on the individual case, but are generally we are looking to distinguish between multiple vestibular diagnoses. Some combination of vestibulo-ocular, gaze stability, calorics, audiological, positional, functional balance, gait, VNG, and VEMP testing will be employed. A thorough review of all of these tests will tell your providers if you have another vestibular diagnosis that could better account for your symptoms. If no other diagnosis is the most logical, and you fit the International Classification of Headache Disorders criteria, you will receive the proper diagnosis of Vestibular Migraines. 

The International Classification of Headache Disorders criteria currently consist of: ₍₄₎

• At least 5 episodes of vestibular symptoms of moderate or severe intensity lasting 5 minutes to 72 hours
• Current or previous history of migraines with or without aura according to the ICHD classification
• One or more of the following migraine features with at least 50% of vestibular episodes:

1. 1. Headache with at least 2 of the following characteristics
   2. One-sided location, pulsating quality, moderate or severe pain intensity; photophobia or phonophobia
   3. Visual aura

• Not better accounted for by another vestibular or ICHD diagnosis

All healthcare providers have access to this diagnostic criteria, and if they can’t find it on the internet, you can always come back and find it here! If you have gone through the diagnostic process and this is you, it’s time to start treating the cause of your symptoms. 

Treatment

Once you receive the Vestibular Migraine diagnosis, both prevention and acute treatments become important! Treating your migraines acutely means decreasing symptoms when you have a migrainous episode. Alternatively, treating your migraines preventatively is going to be a constant process and involves dedication from you and your healthcare team. There is no specific protocol for treating Vestibular Migraine, but both anecdotally and in research we have found effective tools for managing symptoms. The combination of acute and preventative treatments, as opposed to doing one or the other, is the most effective way we have found to treat Vestibular Migraines.

Acute treatments are what we call abortive — the concept is to get rid of the attack right as it is happening so it has a decreased impact on your life. These treatments are usually medications.  (2, 3, 5)

• Aspirin
• Ibuprofen
• Isometheptene mucate, 
• Triptans (Imitrex and Relpax)
• BetaBlockers
• Topiramate 
• Triptans
• Benzodiazepines
• Antihistamines
• Timolol eye drops
• Neuromodulation devices

** please remember that medication overuse headache exists, and herefore meds like triptans, NSAIDS, and others in this list can cause rebound attacks!**

These acute treatments are used in response to the onset of a migraine or Vestibular Migraine symptoms. They all work differently, and you should treat your symptoms based on the treatment you find to be most effective with your healthcare team. You may use one, you may use more than one, but these are all tools that you should have around that you likely won’t be using daily. Daily treatments and prevention are going to be specific to you as well, and will become part of your daily routine.
Chronic prevention of your migraines, and treatment of symptoms that are left over from previous attacks, consist of diet modifications, physical activity, and vestibular therapy. Modifying your food and fluid intake is the most valuable and controllable tool you have to prevent migraines and avoid vertiginous symptoms. You can find out more about items to avoid on a migraine diet in a post I wrote here. However, the basics include decreasing sodium, eliminating caffeine, and eating fewer processed foods!
Other preventatives for migrainous symptoms are medications like beta-blockers, anticonvulsants, and SSRI’s (3). Combining diet changes, lifestyle modifications, some medications, and vestibular therapy will help you reduce symptoms and get back to the activities you love most!

Physical Therapy

Physical therapy for Vestibular Migraine is a gradual process of reintroducing irritating stimuli in a way that your brain can recover from quickly. Like most vestibular therapy, your PT will help determine what stimuli your brain has trouble processing and then help you relearn how to process the stimulus. I find that individuals with Vestibular Migraine frequently struggle with patterned carpets, fluorescent lightning, visual tracking, and quick head movements. All of these stimuli can be very irritating, and it’s your therapist’s job to slowly reintroduce them in a way your brain learns is safe and calm. Adhering to your home program is going to be imperative to your success in vestibular rehabilitation. Your brain  is very malleable, and you will heal from this given time and proper treatment!

Sources:

(1) Rothrock, J., MD. (2020). What is Migraine? Retrieved September 02, 2020, from https://americanmigrainefoundation.org/resource-library/what-is-migraine/

(2) Tepper, D. (2015, November 12). Migraine Associated Vertigo. Retrieved September 02, 2020, from https://americanmigrainefoundation.org/resource-library/migraine-associated-vertigo/

(3)Kramer, J. (2020, August 21). Vestibular Migraine. Retrieved September 03, 2020, from https://vestibular.org/article/diagnosis-treatment/types-of-vestibular-disorders/vestibular-migraine/

(4)Hilton, D. (2020, June 07). Migraine-Associated Vertigo (Vestibular Migraine). Retrieved September 03, 2020, from https://www.ncbi.nlm.nih.gov/books/NBK507859/

(5) Wolf, A. (2020, May 08). Acute Treatments for Vestibular Migraine. Retrieved September 03, 2020, from https://thedizzycook.com/acute-treatments-for-vestibular-migraine/