Vestibular migraine without headache treated with lomerizine: A 35‐year‐old woman undiagnosed for 10 years

Abstract A 35‐year‐old woman presented with recurrent vertigo without headache, which had persisted for 10 years. Detailed medical history revealed that she experienced hearing loss, tinnitus, nausea, photophobia, phonophobia, and slight discomfort in the head during vertigo attacks, which often led to absence from work. Based on the diagnostic criteria of the International Classification of Headache Disorders, third edition, she was diagnosed with vestibular migraine and was prescribed lomerizine, as prophylaxis. Her symptoms markedly improved, enabling her to go to work. Accurate diagnosis and treatment are important for improving the quality of life of patients, since vestibular migraine is commonly underdiagnosed.


| D ISCUSS I ON
Our case study revealed the following: Vestibular migraine can remain undiagnosed for an extended period of time, detailed evaluation of medical history can contribute to the diagnosis, and lomerizine may be effective in preventing vestibular and common migraines.
Vestibular migraine without headache can easily remain undiagnosed for an extended period of time, unless confirmed by physicians, which usually entails obtaining a highly detailed medical history. The patient did not have a personal history or family history of medically confirmed migraine. We considered the repeated episodes of head discomfort consistent with migraine attack. It was reported that 64% of patients with vestibular migraine who had vertigo or dizziness did not present with headache at the time of their attack. 2 Some surveys of the general population in the United States and Germany reported that only 10%-21% of patients with vestibular migraine with or without headache, who met the criteria for vestibular migraine, were correctly diagnosed, 1,3 while the remaining patients were misdiagnosed with benign paroxysmal positional vertigo, Meniere's disease, anemia, diabetes, cervical vertigo, dehydration, and somatic symptoms during repeated episodes. 3,5 Moreover, in Japan, insufficient identification of the symptoms among physicians impedes proper diagnosis of vestibular migraine. 7 Misdiagnosed patients are usually prescribed vestibular suppressants, instead of migraine-specific treatments.
In our case, the patient was diagnosed with vestibular migraine 10 years after the onset of symptoms. We consider that her medical history, including acute spontaneous vertigo which did not resolve at rest, persistent symptoms regardless of vestibular suppressants, and complete remission during the interval period, might be the key information that differentiates the case from other diseases.
Lomerizine, a calcium channel blocker, which selectively affects the cerebral circulation, may be effective in preventing vestibular and common migraines. Although the pathophysiology of vestibular migraine has not been fully elucidated, it might involve neuroanatomical pathways to and from central vestibular structures and neurochemical modulation via the locus coeruleus and raphe nuclei.
In general, the treatment and prevention of vestibular migraine are adopted from those for common migraine (for acute treatment: rizatriptan, zolmitriptan, 8 or metoclopramide; 9 for preventive treatment: flunarizine, venlafaxine, or propranolol 10 ). No large-scale clinical trials have evaluated the effect of lomerizine, which belongs to the same class as flunarizine. We prescribed rizatriptan, metoclopramide, and lomerizine to our patient, and the severity and frequency of her symptoms improved remarkably. We consider the preventive treatment to have mainly contributed to the improvement of the severity of the disease.
Our patient's symptoms were quite severe that she considered leaving her job. According to reports, 40% of patients with vestibular migraine missed work because of their symptoms. 3 Accurate diagnosis and treatment of vestibular migraine are crucial for decreasing the social burden of the disease and improving quality of life.
In conclusion, vestibular migraine without headache can easily remain undiagnosed for an extended period of time. Lomerizine may be effective in preventing vestibular and common migraines.
Accurate diagnosis and treatment of vestibular migraine may improve health-related quality-of-life outcomes in working-age individuals.

CO N FLI C T O F I NTE R E S T S
The authors have stated explicitly that there are no conflicts of interest in connection with this article.