Vestibular Migraine
It has long been recognised that patients who suffer from migraine headaches can have associated dizziness with the headache. In fact after nausea, dislike of loud noise and bright lights, this is the most common associated symptom. However, some people who suffer from migraine can, at times, have dizziness episodes in the absence of the migraine headaches and this is termed vestibular migraine. Dizziness episodes related to migraine can remain a problem even when the migraine headaches are a thing of the past.
Diagnosis
Key points
In common with a number of other causes of dizziness, there is no specific test for vestibular migraine. Rather the diagnosis is made from careful enquiry into the nature of the symptoms, thorough examination and appropriate investigation to exclude other causes as indicated.
If a person is suffering from episodic dizziness and has a history of migraine (either current or in the past) and if no other cause for their symptoms is identified then a provisional diagnosis of vestibular migraine is made and treatment commenced (as below).
Associated symptoms;
dislike of loud noise and bright lights during the attack
nausea, vomiting, sweating and/or diarrhoea during the attack
tiredness and/or a need to go to the toilet after an attack.
visual symptoms during an attack such as blurring or flashing lights
travel sickness, motion intolerance
tinnitus, aural pressure
Treatment
medicines commonly prescribed to deal with migraine headaches during or as an attack commences (tryptans) are largely ineffective in treating the dizziness symptoms.
Management is based on trying to prevent the episodes occurring and is effectively the same as for migraine headaches;
Lifestyle modifications
In general it is best to aim for a regular pattern to lifestyle;
Common triggers are hunger, dehydration, stress and changes to routine. Specific foods are linked to migraine in only around 10-20% of cases.
regular sleeping patterns
regular meals and remaining well hydrated
avoidance of stress
avoidance of bright light, loud noise, strong smells
diet- most people can eat what they like. A few will note a definite relationship to eating or drinking esp alcohol. Certain foods may provoke symptoms in certain individuals. It is not straightforward to identify these as symptoms may not be provoked every time a causative food is eaten and the symptoms can occur hours later. Avoidance of MSG, caffeine, alcohol esp red wine, nitrates may be considered. Chocolate is controversial and may in fact be related to a craving before an attack rather than causing the attack.
Red wine has been implicated for some because of high content of tyramine also found in soft cheeses.
MSG, nitrates and aspartame are linked to migraine for some individuals although evidence is not strong for most people.
Strenuous unaccustomed exercise can cause an attack
may be linked to menstruation in some cases
keeping a migraine diary can be helpful to try and identify possible triggers
Medications
Vitamin supplements
riboflavin 200mg twice daily. Not available on prescription but can be purchased in health food shops and online
magnesium 400-600 mg- can cause diarrhoea - may be particularly useful if symptoms associated with menstrual cycle
co-enzyme Q10, 150mg daily- no adverse side effects reported
Drug treatments
In general medicine dosage is slowly built up until the symptoms are brought under control or until the maximum dose is reached. A given medicine should be taken for at least two- three months at maximum tolerated dose before it is decided whether it is effective or not. The aim of drug treatments is not necessarily to prevent every attack of dizziness but to provide substantial improvement in symptoms. As migraine is cyclical, long-term treatment is rarely warranted. After six months of effective treatment consideration can be given to reducing and stopping the medicine to assess whether it is still required.
Antidepressant amitryptilline or nortryptilline - dose 10-150mg - two hours before bedtime- side effects- dry mouth, sedation, dizziness, nausea
Antihypertensive- propranolol as sustained release- dose 40-240mg - or atenolol 25-100mg- side effects- cold extremities, reduced exercise tolerance, dizziness
Anti-epileptic- topiramate 25-100mg- side effects- tingling sensations which usually resolve with continued use, loss of appetite and weight, kidney stones, depression, mood alteration, cognitive impairment.
Hormonal changes related to menstruation, pregnancy, commencing oral contraceptive can influence vestibular migraine