September 2024

NEUROSCIENCES

ADVANCES IN THE DIAGNOSIS AND TREATMENT OF VESTIBULAR MIGRAINE AND VESTIBULAR DISORDERS MIMCS

A publication featured in The Journal of the American Society for Experimental Neurotherapeutics, co-authored by Nicholas E.F. Hac, MD, discusses the advances in diagnosis and treatment of vestibular migraine along with the vestibular disorders it mimics.

Dr. Hac discusses both traditional and advanced treatments for vestibular migraine. Since vestibular migraine often resembles or co-exists with other vestibular disorders, he provides information about their overlapping and distinguishing features. Lastly, he offers evidence-based recommendations and insight into managing these conditions, with an emphasis on the management of vestibular migraine. 

Learn more about the advances in the treatment of vestibular migraine.

Features of Vestibular Migraine and Its Vestibular Mimics​

Vestibular Migraine (VM)
Diagnosis:
  • Current or past history of migraine headaches
  • 5+ attacks of vertigo between 5 ​min and 72 ​hours
  • At least half associated with migraine headaches, photophobia and phonophobia, or visual aura
Special considerations: 
  • Often triggered or exacerbated by visual stimuli or complex sensory cues
  • Associated with migraine specific triggers
Disease Similarities to VM
  • N/A
Disease Differences from VM
  • N/A

​Persistent Postural-Perceptual Dizziness (PPPD)
Diagnosis:
  • Sense of dizziness most days lasting at least hours each day
  • Ongoing 3+ months-Exacerbated by upright posture, active or passive motion
  • Exacerbated by exposure to complex visual stimuli
Special considerations: 
  • Oftentimes a triggering event can be identified
Disease Similarities to VM
  • Exacerbated by passive motion, visual stimuli, complex visual cues
  • Anxiety symptoms may co-exist
Disease Differences from VM
  • Symptoms typically present more often than not
  • Symptoms continuous and ongoing >3 months (VM more commonly episodic)

Benign Paroxysmal Positional Vertigo (BPPV)
Diagnosis:
  • Presents with attacks of vertigo lasting <1–2 min
  • Occurs with head movements
  • No other neurologic or otologic symptoms
  • Classic nystagmus patterns noted on positional testing
Special considerations: 
  • Diagnosed by examination during positional testing
  • Treated with canalith repositioning maneuvers
Disease Similarities to VM
  • May present with positional episodic dizziness
  • May present with ongoing vertigo in certain positions (e.g., cupulolithiasis)
  • May present with geotropic or apogeotropic nystagmus (e.g., lateral canal BPPV)
Disease Differences from VM
  • Associated with a crescendo-decrescendo nystagmus pattern in positional testing
  • Not associated with neurologic or otologic symptoms
  • Typically triggered only by active motion

Post-Concussive Syndrome (PCS)
Diagnosis:
  • Occurs after trauma
  • Continuous or episodic dizziness
  • Associated with headache, cognitive and/or emotional symptoms, sleep disturbance, initial LOC or amnesia, photophobia, phonophobia, visual focusing issues, fatigue
Special considerations: 
  • May be associated with convergence insufficiency, abnormal smooth pursuit, and/or accommodative dysfunction
Disease Similarities to VM
  • Symptoms of headache, photophobia, phonophobia, visual complaints, fatigue
Disease Differences from VM
  • Typically, symptoms with a trend of improvement after traumatic event (VM more likely spontaneous and episodic)

Meniere’s Disease (MD)
Diagnosis:
  • 2+ attacks of vertigo between 20 ​min and 12 ​hours
  • Audiogram demonstrating low to mid-frequency sensorineural hearing loss
  • Fluctuating aural symptoms in the affected ear
Special considerations: 
  • May be associated with vestibular dysfunction ipsilateral to hearing loss
Disease Similarities to VM
  • May be associated with aural symptoms (fullness, tinnitus, subjective hearing loss)
  • May be associated with unilateral vestibulopathy
Disease Differences from VM
  • Aural symptoms more commonly unilateral (VM symptoms more commonly bilateral)
  • Audiogram evidence of sensor neural hearing loss

Stroke/ Transient Ischemic Attack (TIA)
Diagnosis:
  • May present as AVS or EVS
  • May be associated with neurologic symptoms
  • May be associated with central ocular motor deficits
Special considerations: 
  • Consider MRI and vascular imaging when ABCD2 >3 in AVS
  • Red flag features warrants MRI
  • Perform HINTS exam on patients presenting with AVS
  • Acute hearing loss warrants MRI
Disease Similarities to VM
  • May be associated with neurologic symptoms (VM may present as complex migraine)
  • May be associated with central ocular motor deficits
Disease Differences from VM
  • Abnormal MRI
Nicholas E.F. Hac, MD, Assistant Professor of Hospital and Comprehensive Neurology at Northwestern Medicine​

Refer a Patient

Northwestern Medicine welcomes the opportunity to partner with you in caring for your patients. ​

You May Also Like