Vestibular migraine is a form of migraine in which the symptoms of dizziness come to the fore, not headaches. It develops as a result of complex neurophysiological mechanisms provoked by psychological, physiological or exogenous triggers. The disease proceeds in the form of attacks lasting up to 72 hours, including prodrome, aura with intense dizziness, severe headache. Diagnosis requires a clinical assessment of symptoms, an extended ENT diagnosis, and an MR scan of the brain. Analgesics, serotonin drugs, histamine preparations are used to treat an attack.
Vestibular migraine (VM) accounts for up to 10% of all cases of migraine, can occur at any age. Women get sick 3 times more often than men. VM occupies up to 11.5% among other forms of vertigo, is in 4th place after paroxysmal positional vertigo, phobic postural vertigo, central vestibular syndromes. It is assumed that the disease has a greater share in the structure of neurological pathology, however, due to the insufficiency of objective criteria, it is not always possible to correctly assess the symptoms, diagnose and choose treatment in time.
The etiological structure of the vestibular form of migraine practically does not differ from the causes of the classical variant of the disease. Pathology has a polyethological character, a significant place is occupied by a hereditary predisposition, as a result of which women suffer from VM much more often than men. The development of migraine attacks is associated with triggers (provocateurs), which are grouped into 4 groups:
- Psychological. Stress ranks first among predisposing factors. It triggers symptoms of vestibular migraine in 77% of patients. Less often, pathology is provoked by increased mental stress or strong emotional experiences.
- Food. The likelihood of paroxysm increases dramatically with the use of red wine, cheese, nuts, chocolate and other cocoa-containing products. At the same time, hunger is also a trigger for migraines.
- Physiological. In 72% of women, migraine symptoms are provoked by menstruation. Also, this category includes physical fatigue, sleep disorders, wearing tight-fitting hats or permanent fixation of hair in tight tails / bunches.
- Exogenous. Typical triggers include flashes of light (65%), intense odors (61%), changes in atmospheric pressure, sudden changes in weather, staying in unventilated rooms.
In modern neurology, the concept of a combination of central and peripheral pathophysiological processes in the development of symptoms of vestibular migraine is generally accepted, but the exact neuronal mechanisms of the disease have not yet been established. Great importance is given to the defect of voltage-dependent calcium channels, which is caused by an autosomal dominant mutation and causes disturbances in the processes of excitation and inhibition in the central nervous system.
In recent years, the influence of stimulating neurotransmitters (serotonin, norepinephrine, dopamine), which change the state of neurons that determine the position of the body, and provoke spontaneous systemic dizziness or dizziness when turning the head, has been discussed. Pathogenesis is associated with the commonality of cranial nociceptive and vestibular pathways, which results in their simultaneous activation under the action of neurotransmitters.
A critical role in the development of VM can be played by the spread of cortical depression to the central calves of the vestibular analyzer, which triggers characteristic balance disorders against the background of classical migraine. Experimentally, a connection was established between the trigeminal nerve nuclei and the vestibular zones, on the basis of which it was suggested that spontaneous episodes of dizziness appeared in response to severe pain stimulation.
The disease proceeds according to the classical scheme, begins with a period of prodromal phenomena. Symptoms last from several hours to two days, manifest emotional instability, hypersensitivity to external stimuli, causeless fatigue. Some of the VM sufferers note painful tension of the neck muscles, digestive disorders, and changes in taste preferences.
In most patients, typical symptoms appear at the aura stage. About 67% of patients report spontaneous dizziness, while in the rest it occurs as a result of head movements, moving objects in the field of vision. Dizziness is accompanied by instability of posture (91%), balance disorders (87%), tinnitus (38%). Other aura symptoms are often present: visual, auditory, olfactory.
With VM, at least 50% of seizures should be accompanied by typical headache, which are unilateral in nature, worsen with physical or emotional stress, change their localization with subsequent paroxysms. The painful phase of migraine in an uncomplicated version of the course lasts no more than 72 hours. Dizziness persists throughout the entire painful episode or stops shortly after its appearance.
If, with active treatment, the headache does not stop for more than 3 days, a migraine status is diagnosed – a dangerous condition that is accompanied by repeated vomiting, severe vestibular disorders, general exhaustion of the body due to the inability to eat. With untimely treatment, there is a risk of developing convulsive syndrome, edema-swelling of the brain, cerebral hemorrhage.
A life-threatening consequence of vestibular migraine is considered a migraine stroke, which can begin at any moment of the attack. The condition is manifested by focal neurological symptoms, aggravation of the existing clinical picture. In 14-15% of cases, VM is transformed into a chronic form, which is characterized by the presence of symptoms for more than half of the days in each month and the absence of an effective result from treatment.
Vestibular migraine is a clinical diagnosis, for its formulation there are criteria approved by the International Classification of Headache of the 3rd revision (2018). According to it, classical migraine cephalgia should be accompanied by moderate or severe vestibular symptoms lasting from 5 minutes to 3 days, in the absence of other reasons for the appearance of dizziness. To clarify the diagnosis, the following diagnostic methods are prescribed:
- Clinical examination. During the initial examination by a neurologist, reflex activity, muscle strength, and different types of sensitivity are evaluated. It is advisable to find out the safety of cognitive functions, the emotional status of the patient.
- Consultation of an otolaryngologist. Since episodes of dizziness can be provoked by organic diseases of the inner ear, it is necessary to examine a specialized specialist with an audiogram, Rinne and Weber tests, rotational, thermal, mechanical tests.
- Neuroimaging. To exclude organic pathologies that cause dizziness and cephalgia, an MRI of the brain with contrast is performed as the most informative and safe method. With vestibular migraine, there are no visual symptoms of the disease on MRI images.
The therapy of the condition consists of two directions: emergency medical care at the time of the attack to relieve symptoms and long-term preventive treatment for effective control of pathology. Therapy is mainly carried out on an outpatient basis, hospitalization is indicated with the threat of a complicated course of the attack. Symptomatic treatment includes the following groups of drugs:
- Ergot alkaloid derivatives. The drugs are alpha-blockers, thereby narrowing intracranial vessels, eliminating the pathogenetic mechanism of migraine.
- Analgesics. For moderate headaches, painkillers from the group of nonsteroidal anti-inflammatory drugs, combined medications with antispasmodics are effective.
- Serotonin-series drugs. They are prescribed for the treatment of severe migraine attacks that could not be stopped with medications of the previous groups.
- Histamine analogues. To eliminate dizziness, treatment with drugs that normalize the functioning of the structures of the inner ear is indicated.
Patients who have symptoms more than 2 times a month have severe seizures, neurological disorders are present, preventive treatment is recommended to reduce the frequency of episodes of the disease. For this purpose, antidepressants, anticonvulsants, beta-blockers are used. With a tendency to arterial hypotension, ergot preparations are added to the scheme, with a tendency to hypertension, calcium channel blockers are added.
If symptoms occur during menstruation in women, the issue of hormonal background correction is considered. Non-drug methods of treatment are widely used: cognitive behavioral psychotherapy, biofeedback, exercises on a stability platform for resistance training. Physiotherapy procedures show a good effect: massage of the cervical-collar zone, transcranial electrical stimulation, acupuncture.
Prognosis and prevention
In patients who have received adequate treatment in a timely manner, the prognosis for life is favorable. However, in most cases, there is a moderate decrease in the quality of life, deterioration in performance, correlating with the frequency and intensity of seizures. A less optimistic prognosis for a complicated course, the development of acute life-threatening conditions (migraine status, stroke), resistance to treatment.
To prevent seizures, patients are recommended to adjust their lifestyle in such a way as to exclude individual triggers as much as possible. Moderate effectiveness is shown by a change in eating habits: a complete rejection of alcohol, a reduction in the consumption of foods rich in tyramine (chocolate, cheeses, nuts). When prescribing preventive treatment, it is important to follow the drug regimen, not to stop or change it without permission.