Dizziness and Vertigo: Recognizing Vestibular Migraine in the Primary Care Setting
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Expires June 30, 2015
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Vestibular migraine (VM) is the most common cause of recurrent dizziness and vertigo but is often unrecognized by health care providers. VM causes significant impairment in level of function and quality of life, and the diagnosis should be considered when symptoms cannot be explained by other etiologies. Information and guidance are provided to raise clinicians’ awareness of VM in order to increase accurate diagnosis, guide management decisions, and improve patient health outcomes.
Vestibular migraine (VM) is the most common cause of recurrent dizziness and vertigo but is often unrecognized by health care providers. VM causes significant impairment in level of function and quality of life, and the diagnosis should be considered when symptoms cannot be explained by other etiologies. Information and guidance are provided to raise clinicians’ awareness of VM in order to increase accurate diagnosis, guide management decisions, and improve patient health outcomes.
Headache and dizziness are common reasons for primary care visits. In the general population, the prevalence of migraine is 13% to 16%, while dizziness and vertigo affect approximately 20% to 30%.1 Despite the prevalence of these conditions, many providers are unaware of vestibular migraine (VM) and may overlook it when considering differential diagnoses for these symptoms.
This is not surprising since, until recently, the International Headache Society’s (IHS) International Classification of Headache Disorders (ICHD)—considered the “gold standard” for defining and diagnosing headaches across all medical specialties—included no diagnostic criteria for VM.2 The second edition of the ICHD, ICHD-2, identified vertigo as a symptom of migraine only in the context of basilar migraine.1 Since fewer than 10% of patients with both vertigo and migraine met the criteria for basilar migraine, most VM patients could not be correctly classified under ICHD-2.1
In 2012, the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the IHS jointly published diagnostic criteria for VM.3 These criteria are included in the beta version of ICHD-3, published on the IHS website on July 3, 2013, for immediate use and field testing before ICHD-3 is finalized.4
DIAGNOSTIC CRITERIA FOR VM
The criteria for diagnosis of VM are as follows4:
A. At least five episodes fulfilling criteria C and D
B. A current or past history of migraine without aura or migraine with aura
C. Vestibular symptoms of moderate or severe intensity, lasting between 5 min and 72 h
D. At least 50% of episodes are associated with at least one of the following migrainous features:
- Headache with at least two of the following four characteristics:
a. Unilateral location
b. Pulsating quality
c. Moderate or severe intensity
d. Aggravation by routine physical activity - Photophobia and phonophobia
- Visual aura
E. Not better accounted for by another ICHD-3 diagnosis or by another vestibular disorder
Vestibular symptoms include3
• Spontaneous vertigo, which can be internal (false sensation of self-motion) or external (false sensation that surroundings are spinning)
• Positional vertigo (after change in head position)
• Visually induced vertigo (triggered by a complex or large moving visual stimulus)
• Head motion–induced vertigo
• Head motion–induced dizziness with nausea (dizziness is a sensation of disturbed spatial orientation)
Moderate vestibular symptoms interfere with, but do not prevent, daily activities; severe vestibular symptoms impede them.
On the next page: Diagnosis Overview >>
