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What Is Migraine-Associated Vertigo?

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I would like to begin, not with a definition, but with a story from Paul Auster’s novel, Mr. Vertigo:
“I felt a little light-headed, but it seemed that the crisis had passed. But then I stood up and it was precisely then that the headache returned, ripping through me with a blast of savage, blinding pain. I tried to take a step, but the world was swimming undulating, like a belly dancer in a fun-house mirror, and I couldn’t see where I was going. By the time I took a second step, I had already lost my balance. If the master hadn’t been there to catch me I would have fallen flat on my face again.”
Migraine-associated vertigo is dizziness that is associated with a migraine headache condition. Dizziness is one of the most common reasons people present to the doctor. Headaches are common as well. Dizziness presenting as part of a symptom complex, including headaches, is also common. The job of the diagnostician is to determine whether the dizziness and headache are related and then, whether the dizziness is a manifestation of migraine, or whether they co-exist by chance.
MIGRAINE CAUSES FAR MORE VERTIGO THAN ANY OTHER CONDITION
In patients with migraine-associated vertigo, the first symptoms to appear are typically headache, with vertigo beginning several years later.
Allow Me To Get A Little Technical About The Pathophysiology Of Migraine-Associated Vertigo

              Alternatively, feel free to take a ten minute nap…         

The pathophysiology of migraine is not completely understood, nor is that of migraine-associated vertigo. However, both central and peripheral defects have been observed. Timothy Hain, M.D. of Chicago Dizziness and Balance at Northwestern University recently proposed an updated theory.
According to his theory, we start with a patient who has a hyperexcitable brain. Add to that, environmental events which push the individual’s brain past a threshold, leading to electrical changes (cortical spreading depression (CSD), which causes aura. CSD also stimulates the trigeminal nucleus caudalis (TNC), as well as the release of inflammatory neuropeptides (CGRP). CCRP cause vasodilation and sensitization (allodynia) in the trigeminal nerve circuit. Pain and sensitization lead to a positive feedback loop.
Why vertigo as a manifestation of migraine? John Carey, M.D. of John Hopkins, recently presented the following hypothesis: The blood vessels of the cochlea and vestibular labyrinth are innervated by branches V1 of the trigeminal nerve. This causes plasma extravasation with substance P in the stria vascularis and cochlear tissues.
If the neuropeptide release that Hain talks about is asymmetric, it results in the sensation of vertigo. If it is symmetric, the patient feels an increased sensitivity to motion due to an increased vestibular firing rate during head movements. It has also been suggested that CGRP and other neuropeptides produce a prolonged hormone-like effect as these diffuse into the extracellular fluid. This may explain the prolonged symptoms in some patients with migraine-associated vertigo, as well as the typical progression of persistent spontaneous vertigo followed by benign positional vertigo and then motion sensitivity.
There have also been studies suggesting multiple genes underlying MAV, but these have not yet been found.
Thanks to those who stayed awake :)
Symptoms of Migraine-Associated Vertigo

              According to the literature…

Migraine-associated vertigo may manifest as episodic rotational vertigo with or without nausea and vomiting, positional vertigo, constant imbalance, movement-associated dysequilibrium, illusory self or object motion, head motion intolerance, and/or light-headedness.
Migrainous symptoms during vertigo may occur, such as photophobia, phonophobia, osmophobia, and/or visual or other auras. There is usually minimally or no nystagmus (rapid eye movements), which differentiates it from other peripheral vestibular syndromes. Tinnitus (ear noise) and hearing loss are not as common but do occur. Symptoms may appear during before or during the headache – or – often during headache-free intervals, although a headache is not required to make the diagnosis of migraine-associated vertigo.
Vertigo is a vestibular disturbance whereas dizziness is not. Vertigo includes a feeling of rotation and/or illusory sensations of motion. Dizziness is a feeling of light-headedness, giddiness, drowsiness, and/or impending faint.
Migrainous symptoms during vertigo may occur, such as photophobia, phonophobia, osmophobia, and/or visual or other auras. There is usually minimally or no nystagmus (rapid eye movements), which differentiates it from other peripheral vestibular syndromes. Tinnitus (ear noise) and hearing loss are not as common but do occur. Symptoms may appear during before or during the headache – or – often during headache-free intervals, although a headache is not required to make the diagnosis of migraine-associated vertigo.

Vertigo is a vestibular disturbance whereas dizziness is not. Vertigo includes a feeling of rotation and/or illusory sensations of motion. Dizziness is a feeling of light-headedness, giddiness, drowsiness, and/or impending faint.

 The Real Story – Symptoms Felt by Sufferers Of Migraine-Associated Vertigo

              You have to live it to really know…

Okay, people, that’s what the literature says, but as a previous sufferer and a member of a forum of sufferers, I can tell you more. The symptoms go on 24/7 for many years. I know a woman who has had MAV for 23 years. Common symptoms are crushing fatigue, brain fog, surrealism, as if looking through a coke bottle, visual snow so dense it’s hard to make out people’s faces, bed swings, floor drops, (yes, the floor or bed drops out from underneath you! – ah the good ole’ days). Alice-in-Wonderland syndrome symptoms which you have read about on my AWIS lens. Too many symptoms to list.
This is a wicked illness to live with – it’s not “just” feeling dizzy, which would be bad enough – it is a debilitating, life-robbing illness.
What’s frustrating is that friends and family think you are “just” dizzy (if they believe you at all). They don’t understand why you “won’t” eat the chocolate cake they made you, or “won’t” get out of bed and get some sunshine and meet you for lunch.
I woke each morning thinking – shoot, what horrible thing is going to happen today. And I couldn’t wait until bedtime so I could knock myself out so the dizziness would stop and I could fall into oblivion.
When I talk to a new MAVer today and ask if there is ever a time they feel good, they typically say “when I’m sleeping.” I don’t even try to hold back my tears.
 Diagnosing Vertiginous Migraine

              Is it migraine, vertigo or both?

No diagnostic tests specific for migraine-associated vertigo exist. Careful history-taking is essential. Timothy Hain, M.D. of Chicago Dizziness and Balance at Northwestern University makes his diagnoses according to the following conditions: 1) A patient who presents with migraine with aura, with concurrent episodes of vertigo. 2) A patient who presents with migraine without aura repeatedly associated with vertigo just before or during the headache.
Lembert and Neuhauser propose criteria for definite and probable migraine-associated vertigo:
Definite migraine-associated vertigo A. Episodic vestibular symptoms of at least moderate severity B. Current or previous history of migraine according to the 2004 criteria of the HIS C. One of the following migrainous symptoms during at least 2 attacks of vertigo: migrainous headache, photophobia, phonophobia, visual or other auras D. Other causes ruled out by appropriate investigations.
Probable migraine-associated vertigo A. Episodic vestibular symptoms of at least moderate severity B. One of the following: 1. Current or previous history of migraine according to the 2004 criteria of HIS 2. Migrainous symptoms during vestibular symptoms 3. Migraine precipitants of vertigo in more than 50% of attacks: food triggers, sleep irregularities, hormonal change 4. Response to migraine medications in more than 50% of attacks C. Other causes ruled out by appropriate investigations.
They add, in patients with a clear-cut history, no vestibular tests are required.
Other historical criteria which are helpful in making the diagnosis of migraine-associated vertigo are vertiginous symptoms throughout the patient’s entire life, a long history of motion in intolerance, sensitivity to environmental stimuli, illusions of motion of the environment, and vertigo which awakens the patient.
 Treatment of Migraine-Associated Vertigo

              Prophylaxis is where it is…

First line prophylactic approach is strict adherence to the “migraine diet.” David Buchholz, M.D., formerly of Johns Hopkins, in his Book, Heal Your Headache, gives a comprehensive version of the diet. In short, it is recommended to quit all food triggers for three months, in order to rid the body of all metabolites. These foods include, in general, caffeine, chocolate, MSG, processed meats and fish, fermented dairy products, nuts, alcohol and vinegar, citrus fruits, dried fruits along with some other fruits, some vegetables, especially onions, yeast, and aspartame. The three major substances thought to be causative triggers are histamines, phenylethylamine, and tyramine.
If after three months, there is no clear difference, the patient will move onto prophylactic medications. If, however, there is significant help with the removal of trigger foods, the job is to add back foods, one at a time, to find out which food is the culprit.

 Migraine Associated Vertigo Meds

The mechanisms of these meds are not well understood but they work 75% of the time and take weeks to months to work. It is supposed that an MAV patient will, in order to live a symptom-free life, need a vestibular suppressant, as an adjunct.

CSD Blockers: Anticonvulsants

              These probably raise the threshold for CSD and include:

topiramate (Topamax)
Topiramate is about 75% effective. The starting dose is 25 mg and the recommendation is to titrate as needed, in weekly 25 increments, up to 150 mg. Side effects include, but are not limited to, weight loss, hair loss, speech disturbance, difficulty in word-finding and tingling in the hands and feet. Toprimate is $1 a dose.
Other anticonvulsants used include: gabapentin (Neurontin), sodium valproate (Depakote) and levetiracetam (Keppra).
Mysterious Mechanism Agents

              These include beta blockers and L-channel calcium channel blockers

These work 75% of the time.
Any beta blocker will work: propranolol 60 LA, metoprolol 50 XL, or atenolol 50-100 mg a day. Side effects include fatigue, slow pulse and hypotension. It takes one month for them to work.
L-channel calcium channel blockers including: Verapamil which is 75% effective. The mechanism is not well understood, although it possibly blocks TNC or possibly relates to the calcium channel gene. The therapeutic dose is 120-240 mg SR. It takes two weeks to work. The main side effect is constipation. If the patient is not constipated after two weeks, he/she may increase the dose.
Neurochemical Modulators

              Antidepressants

Venlafaxine (Effexor) is 80% effective. Mechanism is not very clear. Effexor is an SNRI and SSRI. It is very useful in managing the sensory amplifications seen in migraine. It is inexpensive. The starting dose is 12.5 mg, increasing slowly to a maximum of 75 mg. Side effects are minor. However, Effexor has a difficult withdrawal syndrome.
Tricyclics – amitriptyline/nortriptyline. Dr. Hain calls these “messy agents.” They work as central antihistamines, and on norepinephrine and serotonin receptors. They accumulate in the body. A weight gain of 25 pounds is not unusual when using these medications.
 Supplements
Supplements are regularly taken by migraineurs and anecdotally many find them helpful.
Riboflavin has been rigorously studied and has demonstrated a reduction of migraine days and hours by 44%, although no reduction in intensity in headache.
The common recommendation for migraineurs is the following:
riboflavin 200 mg a day magnesium 180 mg a day CoQ-10 100 mg a day fish oil 2000 mg a day
A MUST For Anyone With Migraine OR Migraine-Associated Vertigo

              And to get you started on your own migraine program

Heal Your Headache: The 1-2-3 Program for Taking Charge of Your Pain+
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