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| CASE REPORT |
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| Year : 2018 | Volume
: 15
| Issue : 2 | Page : 112-115 |
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Migraine-related vertigo in an elderly male
Santosh Kumar Swain1, Sidhartha Mohanty2, Mahesh Chandra Sahu3
1 Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
2 Department of Anesthesiology and Pain and Palliative Medicine, Apollo Hospital, Bhubaneswar, Odisha, India
3 Directorate of Medical Research, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar, Odisha, India
| Date of Web Publication | 5-Jul-2018 |
Correspondence Address:
Santosh Kumar Swain
Department of Otorhinolaryngology, IMS and SUM Hospital, Siksha “O” Anusandhan (Deemed to be University), Bhubaneswar - 751 003, Odisha
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/am.am_30_18
Migraine-related vertigo (MRV) is a distinct and common clinical entity which accounts for major vestibular symptoms among the adult and children. The pathophysiology for MRV is not completely understood and is always a puzzling dilemma. Patients often present with vertigo, headache, photophobia, and phonophobia. The clinical examinations and laboratory investigations are usually within normal limit. The diagnosis of MRV is often challenging as there are no confirmatory tests available. The treatment is often similar to the migraine headache. It is always a challenging disease for the clinician and often creates a puzzle for diagnosis and treatment. We are presenting a case of MRV in an elderly person which is rare in clinical practice. Keywords: Elderly person, migraine, migraine-related vertigo, vestibular migraine
How to cite this article:
Swain SK, Mohanty S, Sahu MC. Migraine-related vertigo in an elderly male. Apollo Med 2018;15:112-5 |
| Introduction | |  |
Dizziness is a common clinical symptom in daily medical practice. Patient presenting migraine along with vertigo or dizziness is called as migraine-related vertigo (MRV). It is also called as migraine-associated vertigo (MAV), vestibular migraine, migrainous vertigo, or basilar artery migraine. -MRV is a type of migraine results in vestibular symptoms in addition to the typical symptoms of migraine. MRV was first described by Dieterich and Brandt in 1999,[1] and it corresponds to a type of migraine where the main symptom is vestibular. MRV is more prevalent in individuals without aura and predominantly affects female, at a ratio up to 5:1 (female/male).[2] It is documented that 1% of the population suffers with MRV which accounts for the most common central cause of episodic vertigo and second most common cause of vertigo in total.[3] MRV is often confused with vestibular disorders which are an important cause for dizziness complained by the patients. The most common vestibular disorders which manifest in dizziness are benign paroxysmal positional vertigo, vestibular migraine, Ménière's disease, and vestibular neuritis in decreasing order of frequency. MRV represents the second most common cause for vertigo after benign paroxysmal positional vertigo.[4] Here, we are presenting a case of MRV in 65-year-old male.
| Case Report | | |
A 65-year-old male attended vertigo clinic at the Department of Otorhinolaryngology for giddiness, sensations of nausea with a severe headache for the past 3 months. The headache was pulsating nature, confined to the right temporal area and continues for 3–4 h in duration. He had a history of intolerance to sunlight and noise. Although he had dizziness and headache occurring intermittently for 6 months, it was the first time he presented with severity. There was no history loss of consciousness. He has not associated with any medical comorbidity. He is a retired person and having stress due to feeling loneliness after retirement. He is a nonsmoker and does not consume alcohol. Examinations of the ear, nose, and throat were within normal limit. All neurological examinations were normal. Nystagmus was elicited when turning his head to the right side. Pure-tone audiogram and electronystagmography were within normal limits. He is nonhypertensive and nondiabetic. On cardiology consultation, cardiac parameters were within normal limits. He was treated with flunarizine 10 mg once daily for longer period and started antivertigo drug such as cinnarizine (20 mg) plus dimenhydrinate for few days. He was reviewed after 1, 3, and 6 months. His symptoms were improved after 1 month and free from giddiness and headache after 3 months of treatment.
| Discussion | | |
Migraine is characterized by severe, periodic, unilateral pulsating headache persisting for more than couple of hours and often associated with autonomic/neurologic/gastrointestinal problems preceded by an aura. MRV is a variant of migraine resulting in vestibular symptoms such as vertigo along with symptoms of migraine. In MRV, the profile of the patients is commonly young adult female or male and clinical presentations such as dizziness of variable duration and headache. Here, our case is the elderly and age is 65 years which is rarely seen. The basic pathophysiology for migraine is trigeminovascular reflex. Trigeminovascular reflex is a parasympathetic reflex which can cause vasodilatation of the large intracranial vessels [Figure 1]. The activation mediated by trigeminal nucleus caudalis and C1–C2 dorsal horn neurons cause vasodilatation of large intracranial vessels.[5] The vasodilatation effect of parasympathetic stimuli on trigeminovascular reflex may be augmented by neurokinin A, calcitonin gene-related peptide, and substancePreleased from sensory terminals of the trigeminal nerve.[6] The vestibular symptoms resulting from migraine often similar to symptoms of inner ear lesions such as benign paroxysmal positional vertigo and episodic vertigo in Ménière's disease. Patients often complain episodic spinning sensation, imbalance or rotating sensation, or giddiness or lightheadedness from few seconds to hours or to days. The patient often presents with severe episodic pulsating headache. Patient has usually no hearing loss when associated with common and classical migraine. About 80% cases of basilar migraine have sensorineural hearing loss and tinnitus which may mimics the Ménière's syndrome. The peripheral vestibular lesions which mimics to MRV are Ménière's disease, vestibular neuronitis, benign paroxysmal positional vertigo, and perilymph fistula. The central lesions which mimic to MRV are transient ischemic accident, multiple sclerosis, vestibulo-basilar artery insufficiency, neurodegenerative disorders, and familial ataxia syndrome. The International Headache Society (HIS) has declared well-recognized criteria for the diagnosis of migraine [Table 1].[7] However, the vertigo is mentioned in this classification only in respect of basilar migraine and benign paroxysmal positional vertigo. Now, it is thought that the higher prevalence of MRV is more than the chance of association. Migraine may be classified into: (1) Common migraine (migraine without aura) – The headache is often unilateral and pulsating. A headache is aggravated by photophobia (sensitivity to light), phonophobia (sensitivity to sound), and physical activity. All neurological tests are usually normal; (2) Classical migraine (migraine with aura) – There are 2–3 episodes of headache which was proceeded by reversible neurological problems such as ataxia, dysarthria, diplopia, one-side numbness/weakness, vertigo, and tinnitus. This phase is called as aura and neurological tests are within normal limit; (3) basilar migraine (type of classical migraine) – There are features of basilar and vertebral artery spasm. There are clinical symptoms of brainstem hypoxia-like dysarthria, diplopia, vertigo, tinnitus, hearing loss, low level of consciousness, and weakness/numbness of limb. The symptoms stay for few minutes to hours. The headache often originates at the occipital and cervical areas; (4) vestibular migraine/MRV-Vestibular symptoms are additional features due to vestibule-cochlear artery spasm along with classical migraine; (5) complicated migraine/migrainous infraction – it is a classical type of migraine, but the neurological symptoms are not reversible within 1 week and MRI reveals zone of ischemic infraction of the brain. MRV or vestibular migraine was jointly described by Barany Society and the subcommittee of IHS.[8] It is seen in the appendix of the 3rd edition of HIS as the first step for new clinical entities.[9] The criteria for the diagnosis of MRV which are accepted internationally are based on: recurrent vestibular symptoms and migraine symptoms of moderate-to-severe intensity, a past history of migraine, and a temporal association between migraine symptoms and vestibular symptoms. The duration of acute episodes is often limited between 5 min and 72 h. The clinicians should find the presence or absence of aural symptoms to differentiate between Ménière's disease and MRV [Table 2]. MRV is a multifactorial chronic disease and common among genetically susceptible people. It is characterized by headache associated with phonophobia, photophobia, vertigo, nausea, and vomiting, which are seen in our case. MRV affects around 18% females and 6% males presenting neuro-otological manifestations such as vertigo, hearing loss, tinnitus, and aural fullness during crisis. Many patients may present these symptoms in the absence of headache.[10] The physical examination of the patients is often normal between the attacks. During the attack of MRV, patients often show a nystagmus that suggests neither peripheral nor central vestibular abnormality. During the attack of vestibular migraine, nonparoxysmal positional nystagmus is common.[11] Hearing loss is not a clinical feature of common and classical migraine, but 80% cases of basilar migraine have the sensorineural type of hearing loss and or tinnitus resembling the Ménière's syndrome. At the time of aura, spontaneous or positional nystagmus can be seen, whereas patient may not have any neurological deficits. There is often family history of headache is present. The triggering factors are stress, mental, physical, menstrual period, contraceptive pills, smoking, exposure to light and sound, deprivation of sleep, fasting, and certain foods. Vertigo in the migraine patient may precede the headache and be a part of the migrainous aura. It is often difficult to understand whether migraine and vertigo are two different presentations of the same pathophysiology. Routine blood tests such as complete blood count, erythrocyte sedimentation rate, and C-reactive protein are usually done in all cases of MRV. Imaging such as MRI or CT scan of the brain may be helpful to find any intracranial lesions. The accurate diagnosis of MRV needs exclusion of the vestibular symptoms. Videonystagmography often shows positional nystagmus not localizing for a central or peripheral site of lesions. Cinnarizine and flunarizine are calcium channel blockers which inhibit vestibular hair cells stimuli and used in the treatment of MRV. Dimenhydrinate is a H1 blocker that acts on the vestibular central nuclei and surrounding vegetative center of the brainstem. For prophylactic treatment, flunarizine, cinnarizine, beta-blocker, and dimenhydrinate are used when there are more than three attacks in 2 months.[12] | Table 1: Diagnostic criteria of vestibular migraine/migraine-related vertigo (International Headache Society and Barany Society)
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 | Table 2: Difference (clinical presentations) between migraine-related vertigo and Ménière's disease
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| Conclusion | | |
Accurate diagnosis of MRV is often a challenging situation in front of clinicians for diagnosis and treatment. The pathophysiology for MRV is always a puzzling dilemma for clinician. The MRV and its significant impact on quality of life need further understanding of the pathophysiology for better care of MRV. The presence of two symptoms of vertigo and headache simultaneously does not represent a definite causal relationship. Each episode of dizziness is usually rotational sensation and or sense of imbalance which lasts for minutes to hours. Other clinical symptoms are photophobia, phonophobia, bilateral aural fullness, tinnitus, and otalgia. The majority of the MRV patients have past history of motion sickness. Migraine prophylaxis is often helpful for the treatment of MRV.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1]
[Table 1], [Table 2]
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