Clinical Edge

Summaries of Must-Read Clinical Literature, Guidelines, and FDA Actions

Migraine Headache and Episodic Vertigo

Vertigo in migraine is an integral manifestation of migraine, rather than a prodromal or aura symptom, a new study suggests. The Migraine and Neck Pain Survey gathered data from nearly 500 adult participants in a questionnaire-based survey. Researchers re-analyzed patients with episodic migraine with and without aura who experienced episodic vertigo (eV) anytime around their migraine attacks. They defined 3 different time periods. Among the findings:

  • 30% of participants reported eV anytime during their migraine attack; 16% notice eV with the start of the headache, 10% within 2 hours before the headache, and 3% experienced eV 2‒48 hours before the headache.
  • 26.7% of patients could be diagnosed with vestibular or probable vestibular migraine, supporting the clinical association of migraine and vertigo.

Citation:

Lampl C, Rapoport A, Levin M, Bräutigam E. Migraine and episodic vertigo: A cohort survey study of their relationship. [Published online ahead of print April 8, 2019]. J Headache Pain. doi:10.1186/s10194-019-0991-2.

Commentary:

Vertigo and migraine remain tricky in clinical diagnosis and classification. This study suggests episodic vertigo occurs in ~30% of migraine respondents. Vertigo, for most, was “more of a headache phase phenomenon, rather than prodromal.” That said, 16% had vertigo before attacks, again making distinction of the vertigo from aura and prodrome more challenging depending on the time separating episodic vertigo and migraine pain.

Beh et al (Headache 2019;doi: 10.1111/head.13484) described 131 patients with vestibular migraine. Benign paroxysmal positional vertigo was reported in 13%, while 88.6% reported interictal dizziness, not definitely vertigo. Overlap and difficulty in defining where vertigo with the illusion of motion including spinning and non-spinning sensations ends and non-specific dizziness with other vestibular symptoms begin is problematic.

It is clear from these studies that vertigo and vestibular symptoms occupy a spectrum, and will require continued large cohort studies and, probably, functional imaging, to finally clarify relationships of migraine, vertigo, dizziness, comorbid affective disorders, aura, and prodrome. —Stewart J. Tepper, MD, FAHS, Professor of Neurology, Geisel School of Medicine at Dartmouth, Director, Dartmouth Headache Center, Dartmouth-Hitchcock Medical Center, Lebanon, NH