Triological Society Best Practice
What are the diagnostic criteria for migraine-associated vertigo?†
The authors have no funding, financial relationships, or conflicts of interest to disclose.
Migraines are very common and occur with a lifetime prevalence of 13% to 16% in the general population. Vertigo is also common, and the lifetime prevalence is 7%. When comparing the prevalence of these two conditions, the expected combination should be 1.1%.1 The association is closer to 3.2%, with migraineurs 3.8 times more likely to suffer from vertigo than those without migraines. Although there are increasing data to suggest a more than casual relationship between migraines and vestibular and nonvestibular forms of dizziness and vertigo, clinicians are left with the task of diagnosing and treating these patients. Currently, there is no unifying term or internationally approved criterion for migraine-associated vertigo. Without such criteria, determination of the pathophysiology and appropriate treatment regimens for these patients will continue to be elusive.
Neuhauser et al. published “The Interrelations of Migraine, Vertigo, and Migrainous Vertigo” in 2001 to help define an explicit diagnostic criteria for migraine-associated vertigo.2 Their criteria for definite and probable migrainous vertigo (MV) is listed in Table I. Probable MV, a more sensitive/less-specific category, was created for individuals who did not fully qualify as definite, but MV was still the most likely diagnosis. With this structure, they were able to show a statistically significant association between vertigo and migraines, with 38% of dizziness patients having migraines compared with only 24% of controls.
Table I. Diagnostic Criteria for Migrainous Vertigo*
|Episodic vestibular symptoms of at least moderate severity (rotational vertigo, other illusory self or object motion, positional vertigo, head motion intolerance [i.e., sensation of imbalance or illusory self or object motion that is provoked by head motion])||Episodic vestibular symptoms of at least moderate severity (rotational vertigo, other illusory self or object motion, positional vertigo, head motion intolerance)|
|At least one of the following migrainous symptoms during at least two vertiginous attacks: migrainous headache, photophobia, phonophobia, visual or other auras||At least one of the following: migraine according to the criteria of the IHS; migrainous symptoms during vertigo; migraine-specific precipitants of vertigo, (e.g., specific foods, sleep irregularities, hormonal changes); response to antimigraine drugs|
|Migraine according to the IHS criteria|| |
|Other causes ruled out by appropriate investigations||Other causes ruled out by appropriate investigations|
To prove the validity of the groups' diagnostic criteria published in 2001, Radtke et al. (2011) performed a long-term follow-up of those diagnosed with definite or probable vestibular migraine (VM).3 With a mean follow-up time of 8.75 years (range, 5.4–11 years), the diagnosis of definite VM was confirmed in 85% of patients, giving a positive predictive value of 85%. Fifty percent of those with probable VM were reclassified as definite VM, whereas 32% remained at probable. Some patients were reclassified with Meniere's disease with the onset of hearing loss. Sixty-three percent of patients with definite VM had migraine with aura compared with only 22% of probable VM. They were able to show that their criteria was precise with long-term viability, but did not provide evidence about its diagnostic accuracy.
Brantberg et al. in 2005 believed that the Neuhauser criteria was diagnosing too many people with migraine-associated vertigo, because most migraineurs have head motion intolerance and vertiginous individuals often have photo/phonophobia with attacks.4 In an attempt to resolve the broad diagnostic criteria, they studied a more homogenous group of patients with a specific vestibular symptom profile. This group defined migraines by the International Headache Society (HIS) criteria (shown in Table II) and benign recurrent vertigo by: 1) at least three spontaneous attacks of rotational vertigo, 2) episodes lasting at least 1 minute, and 3) no associated unilateral hearing loss. After performing structured phone interviews with individuals suffering from benign recurrent vertigo and migraine, they found imbalance (87%) and nausea (92%) were common with vertigo, whereas headache was present during only 50% of attacks. They concluded that “it is probably not wise to demand a temporal association,” and that diagnostic criterion should be based on pathophysiology, not symptoms.
Table II. The International Classification of Headache Disorders, 2nd Edition7
|A. At least five attacks fulfilling criteria B–D||A. At least two attacks fulfilling criteria B–D|
|B. Headache attacks lasting 4–72 hours (untreated or unsuccessfully treated)||B. Aura consisting of at least one of the following, but no motor weakness: fully reversible visual symptoms including positive and/or negative features, fully reversible sensory symptoms including positive and/or negative features, fully reversible dysphasic speech disturbance|
|C. Headache has at least two of the following characteristics: unilateral location, pulsating quality, moderate or severe pain intensity, aggravation by or causing avoidance of routine physical activity||C. At least two of the following: homonymous visual symptoms and/or unilateral sensory symptoms, at least one aura symptom develops gradually over ≥5 minutes and/or different aura symptoms occur in succession over ≥5 minutes, each symptom lasts ≥5 and ≤60 minutes|
|D. During headache at least one of the following: nausea and/or vomiting, photophobia, and phonophobia||D. Headache fulfilling criteria for migraine without aura begins during the aura or follows aura within 60 minutes|
|E. Not attributed to another disorder||E. Not attributed to another disorder|
Brantberg et al. suggested that there are likely different forms of MV, and research is ongoing to show the similarities and differences between these potential subtypes. Cohen et al. (2011) performed a retrospective chart review of patients diagnosed with VM to better elucidate the specifics of VM.5 Their diagnostic criteria included patients with: 1) migraine according to the HIS, and 2) at least one symptom of VM (i.e., vertigo) and at least one vestibular trigger (i.e., riding trains). According to their research, the most common vestibular symptoms were unsteadiness, balance disturbance, and lightheadedness. Triggers like crowds (tight spaces), fluorescent lights (environmental), and watching trains (motion) were documented. Vestibular symptoms and triggers were more likely to be associated with migraines with auras compared to those without. Their data suggested that even though migraine-associated vertigo is heterogeneous, identifying commonalities can help craft reliable diagnostic criteria. They concluded that their data were insufficient to create criteria and that “a masked field study will be required.”5
As research continues to determine the pathophysiology of migraine-associated vertigo, finding viable treatment options is the desired end point of the controversy. Reploeg and Goebel (2002) performed a retrospective analysis of migraine-associated dizziness (MAD) patients to determine efficacy of migraine treatments in alleviating their dizziness.6 Patients diagnosed with central vertigo who were further classified as having MAD were treated with a sequential treatment plan for migraines. The diagnostic criteria for MAD used by the senior author was not specified. After being followed for an average of 54.5 weeks, use of their treatment algorithm resulted in 72% receiving >75% reduction of their headache symptoms. All but 4 patients experienced resolution of their dizziness similarly to that of their headaches. This study shows that the diagnostic criteria used by the authors were validated by improvement of symptoms with treatment of migraines. Although the diagnostic criteria were not specified, it shows that clinical response can be used to validate diagnostic criteria.
In an ideal world, the pathophysiology of a disease process would dictate its diagnosis. When the mechanisms responsible for that disease process are not fully understood, a set of diagnostic criteria should instead be validated by therapeutic outcomes. While research continues to investigate migraine-associated vertigo, there remains no gold standard diagnostic criteria. The Neuhauser et al. criteria (2001)2 presents a broad-based starting point to help guide clinicians toward diagnosing and treating this increasingly recognized entity.
LEVEL OF EVIDENCE
Currently there is no level 1 evidence available. The articles in this review show level 2b evidence.