Hallazgos vestibulares y oculomotores en migraña vestibular: una revisión actualizada

La migraña vestibular es una de las etiologías más frecuentes del síndrome vestibular episódico a nivel mundial. Presenta varias hipótesis de patofisiología, principalmente a nivel de sistema vestibular central y genético. Su diagnóstico es fundamentalmente clínico, pero se han observado alteraciones a nivel de la función vestibular y de las pruebas oculomotoras. Los hallazgos clínicos no solo están presentes en el momento de la crisis, sino también se han observado en intervalos asintomáticos. La paresia unilateral en la prueba calórica suele ser más frecuente que una ganancia baja del reflejo vestíbulo-ocular del canal lateral en la videonistagmografía, sin embargo, existe una tasa elevada de discordancia entre ambas pruebas. Respecto a la prueba de estudio del movimiento ocular, se han observado alteraciones en el seguimiento pendular, movimiento sacádico, nistagmo optocinético, nistagmo evocado por la mirada, nistagmo espontáneo y nistagmo posicional. Es frecuente observar que el nistagmo provocado por cambios posicionales presenta características centrales durante la crisis de migraña vestibular, pero también se pueden presentar en periodos libres de síntomas en este grupo de pacientes.

Vestibular migraine is one of the most frequent etiologies of episodic vestibular syndrome worldwide. It presents several pathophysiology hypotheses, mainly at the central vestibular system and genetic level. Its diagnosis is fundamentally clinical, but changes in vestibular function and oculomotor tests have been observed. Clinical findings are present not only during the crisis, but also have been seen in the symptom-free interval. Unilateral paresis on caloric testing is usually more common than low gain of the vestibulo-ocular reflex in the lateral canal on videonystagmography, however, there is a high rate of discrepancy between these tests. Regarding the eye movement study test, alterations have been seen in pendulum tracking, saccadic movement, optokinetic nystagmus, gaze-evoked nystagmus, spontaneous nystagmus and positional nystagmus. It is common to observe that nystagmus caused by positional changes has central features during vestibular migraine attacks, but it can also be seen in the symptom-free interval in this group of patients.

Comparison of clinical characteristics and vestibular function test results in patients with vestibular migraine and Menière's disease

Abstract Objectives The differentiation between Vestibular Migraine (VM) and Meniere's Disease (MD) is difficult because of overlapping symptoms. The study aimed to compare the clinical characteristics and vestibular function test results between VM and MD patients. Methods Seventy-one patients with definite VM and 31 patients with definite unilateral MD were included. All patients received Caloric Test (CT), Video Head Impulse Test (vHIT) and Vestibular Evoked Myogenic Potential (VEMP) test within 7 days after visiting the hospital. Results of these tests were compared between groups. Results Most VM patients (64.0%) experienced spontaneous internal vertigo, while most MD patients (66.7%) experienced spontaneous external vertigo. MD patients had more severe vestibular symptoms and autonomic responses compared to VM patients during attacks (p= 0.03, p= 0.00, respectively). The nystagmus intensity of CT-induced was greater in VM patients than in MD patients (p= 0.003). More VM patients had CT intolerance and Central Positional Nystagmus (CPN) compared to MD patients (p= 0.002, p = 0.006, respectively). More MD patients had CT(+) and vHIT saccades wave compared to VM patients (p< 0.001, p= 0.002, respectively). The non-elicitation rate of cervical VEMP was higher, and the ocular VEMP amplitudes were lower in MD patients than in VM patients (p = 0.002, p= 0.018). Conclusions Vestibular symptoms during attacks combined with the results of vestibular function tests may be used to differentiate between VM and MD. The diverse nature of vestibular symptoms (especially internal vertigo), history of motion sickness and CT intolerance may provide clues to the diagnosis of VM, whereas spontaneous external vertigo, CT(+) with vHIT(-), and the presence of saccades may provide clues to the diagnosis of MD. Level of evidence: 4.

Clinical characteristics of definite vestibular migraine diagnosed according to criteria jointly formulated by the Bárány Society and the International Headache Society

Abstract Objective: To investigate the clinical features of patients with definite vestibular migraine (dVM). Methods: A total of 91 patients with vestibular symptoms accompanied by migraines/migrainelike symptoms were enrolled and diagnosed according to the criteria of the Bárány Society and the International Headache Society. Baseline data were collected. Videonystagmography and immune-related laboratory tests were performed. Results: Among the 91 patients, 62 (68.1%) had dVM (11 men, 51 women). Among dVM patients, migraine occurred earlier than vestibular symptoms in 42 (67.7%) patients. Spontaneous vertigo occurred in 41 (66.1%) patients. Induced vertigo occurred in 21 (33.9%) patients. Motion sickness occurred in 33 (53.2%) patients. Central oculomotor dysfunction was observed in 11 (17.7%) patients. Caloric test revealed unilateral horizontal semicircular canal dysfunction in 12 (19.4%) patients. Severe intolerance during the test occurred in 44 (71.0%) patients with dVM. 12 (19.4%) patients showed abnormal immune-related indicators. Conclusion: dVM is more common in women. The onset of migraine precedes that of vestibular symptoms, which are often accompanied by photophobia and phonophobia. Motion sickness and severe caloric test intolerance can contribute to the diagnosis of dVM. Immunological indicators are abnormal in some patients with dVM, dVM may be secondary or an accompanying disorder, but the causal relationship needs further investigation. Level of evidence: IV.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine

Abstract Objective: Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine. Methods: Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Preand post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively. Results: With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups. Conclusion: With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit. Level of evidence: Level III (evidence obtained from well-designed controlled trials without randomization).

The effectiveness of propranolol, flunarizine, amitriptyline and botulinum toxin in vestibular migraine complaints and prophylaxis: a non-randomized controlled study / A eficácia de propranolol, flunarizina, amitriptilina e toxina botulínica nas queixas e profilaxia da migrânea vestibular: um estudo controlado não randomizado

Abstract Introduction: Vestibular migraine is the most common cause of spontaneous episodic vertigo in adult patients and the second most common cause of vertigo in patients of all ages. Objective: To assess the effectiveness of oral medication type (propranolol, flunarizine, and amitriptyline) and botulinum toxin A application on vestibular symptoms, headache severity and attack frequency for vestibular migraine patients. Methods: Sixty patients with vestibular migraine were enrolled. Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B− group). Headache severity was evaluated with Migraine Disability Assessment Scale and vertigo severity was evaluated with Dizziness Handicap Inventory scale. Vestibular migraine attack frequencies in the last three months were also evaluated. Results: There was a statistically significant decrement in mean Dizziness Handicap Inventory scores, Migraine Disability Assessment Scale scores and vertigo attack frequencies after treatment for all patients, B+ and B− group patients (p < 0.001 for all). The mean Migraine Disability Assessment Scale score gains (p < 0.001) and vertigo attack frequency gains (p = 0.003) were significantly higher in the B+ patients than B− patients. Conclusions: Both B+ and B− group patients exhibited significant improvement in vestibular migraine attack frequencies, Dizziness Handicap Inventory score and Migraine Disability Assessment Scale score values. However, botulinum toxin A application had a more pronounced effect for Migraine Disability Assessment Scale score gain and vestibular migraine attack frequency values, but not for Dizziness Handicap Inventory score gain values. Thus, botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. The oral medication type (propranolol, flunarizine or amitriptyline) did not differ in influencing the vestibular migraine attack frequency, Dizziness Handicap Inventory score gain and Migraine Disability Assessment Scale score gain values.

Resumo Introdução: A migrânea vestibular é a causa mais comum de vertigem episódica espontânea em pacientes adultos e a segunda causa mais comum de vertigem em pacientes de todas as idades. Objetivo: Avaliar a eficácia da aplicação dos tipos de medicamentos orais (propranolol, flunarizina e amitriptilina) e da toxina botulínica tipo A sobre os sintomas vestibulares, intensidade da cefaleia e frequência das crises em pacientes com migrânea vestibular. Método: Sessenta pacientes com migrânea vestibular foram incluídos. Trinta pacientes receberam tratamento com toxina botulínica tipo A e medicação oral (Grupo B+), enquanto 30 pacientes receberam apenas medicação oral (Grupo B-). A intensidade da cefaleia foi avaliada pelo migraine disability assessment scale e a gravidade da vertigem foi avaliada com o dizziness handicap inventory. A frequência das crises de migrânea vestibular nos últimos três meses também foi avaliada. Resultados: Houve um decréscimo estatisticamente significativo na média dos escores do dizziness handicap inventory e migraine disability assesment scale e na frequência das crises de vertigem após o tratamento em todos os pacientes, p < 0,001 para todos os pacientes dos grupos B+ e B−. Os ganhos médios no escore do migraine disability assesment scale (p < 0,001) e na frequência das crises de vertigem (p = 0,003) foram significantemente maiores nos pacientes B+ do que nos pacientes B−. Conclusões: Os pacientes de ambos os grupos B+ e B− exibiram melhoria significativa na frequência das crises de migrânea vestibular e nos valores dos escores do dizziness handicap inventory e do migraine disability assesment scale. No entanto, a aplicação da toxina botulínica tipo A teve um efeito mais pronunciado para os valores de ganho no escore do migraine disability assesment scale e na frequência das crises de migrânea vestibular, mas não para os valores de ganho no escore do dizziness handicap inventory. Portanto, a aplicação de toxina botulínica tipo A deve ser considerada para pacientes com migrânea vestibular, cujos graus de intensidade da cefaleia são mais marcantes. O tipo de medicação oral (propranolol, flunarizina ou amitriptilina) não diferiu em relação à frequência das crises de migrânea vestibular e aos valores de ganho dos escores do dizziness handicap inventory e do migraine disability assesment scale.

Postural control at posturography with virtual reality in the intercritical period of vestibular migraine / Controle postural à posturografia com realidade virtual no período intercrítico da migrânea vestibular

Abstract Introduction: Vestibular migraine is a condition that associates headache and vestibular symptoms. Objective: To evaluate body-balance with virtual reality posturography in vestibular migraine. Methods: A total of 26 patients in the intercritical period of vestibular migraine were compared by means of the Balance Rehabilitation UnitMT (Medical/Interacoustics) posturography with 30 controls, paired for age and gender. Results: There was no significant statistical difference (p = 0.121) in the limit of stability area (cm2) between the experimental group and the control group values. There were significant differences (p < 0.05) in the values of sway velocity (cm/s) in nine of ten evaluated sensory conditions and in the pressure center displacement area (cm2) values in eight of those ten sensory conditions in the comparison between the control group and the experimental group. Conclusion: Posturography with virtual reality can identify changes in the sway velocity and the pressure center displacement area, characterizing the inability to maintain postural control with and without visual deprivation in situations of visual conflict and vestibulovisual interaction,in the intercritical period of the vestibular migraine.

Resumo Introdução: A migrânea vestibular é um quadro clínico que associa cefaleia migranosa e sintomas vestibulares. Objetivo: Avaliar o controle postural à posturografia com realidade virtual no período intercrítico da migrânea vestibular. Método: Um total de 26 pacientes com migrânea vestibular no período intercrítico da afecção foram comparados comparados à posturografia do Balance Rehabilitation UnitTM (Medical/Interacoustics) a um grupo controle com 30 indivíduos hígidos pareados por idade e sexo. Resultados: Não houve diferença estatisticamente significante (p = 0,102) entre os valores da área do limite de estabilidade (cm2) entre o grupo experimental e o controle. Houve diferença significante (p < 0,05) nos valores da velocidade de oscilação (cm/s) em nove de dez condições sensoriais avaliadas e nos valores da área de deslocamento do centro de pressão (cm2) em oito destas dez condições sensoriais em comparação entre os grupos controle e experimental. Conclusão: A posturografia com realidade virtual pode identificar alterações da velocidade de oscilação e da área de deslocamento do centro de pressão, o que caracteriza a inabilidade para manter o controle postural com e sem privação da visão, em situações de conflito visual e interação vestibulovisual, no período intercrítico da migrânea vestibular.

Influência do diabetes mellitus na qualidade de vida de indivíduos com migrânea vestibular / Influence of diabetes mellitus on the quality of life of individuals with vestibular migraine

Introdução: qualidade de vida refere-se à percepção de um indivíduo sobre o seu estado físico, emocional e social. No âmbito físico, pode ser impactada negativamente por condições como migrânea vestibular e diabetes mellitus (DM). Objetivo: descrever a qualidade de vida em pacientes com migrânea vestibular, com e sem DM. Metodologia: trata-se de um estudo transversal, descritivo, retrospectivo e secundário, realizado com pacientes com migrânea vestibular, atendidos em uma clínica-escola de Salvador-BA. Foram coletados dados sociodemográficos e clínicos, incluindo o autorrelato de DM. A qualidade de vida foi avaliada por meio do Dizziness Handicap Inventory (DHI), cuja pontuação foi classificada, quanto ao grau de incapacidade, em "leve" (0 a 30 pontos); "moderado" (31 a 60 pontos) e "severo" (61 a 100 pontos). Foram realizados procedimentos estatísticos descritivos por frequência simples e absoluta, medidas de tendência central e dispersão. Resultados: a amostra foi composta por 41 indivíduos, dotados das seguintes características: a idade média foi 42,46 anos (DP = 13,83), predominância do sexo feminino (87,80%), com diabetes (51,21%), com ansiedade (58,54%) e sem depressão (90,24%). A pontuação média do DHI foi de 47,26 pontos (DP = 21,81), classificada como impacto moderado, sendo maior entre os não diabéticos, porém a ansiedade predominou entre os não diabéticos (60%). Conclusões: acientes com migrânea vestibular apresentaram prejuízo de grau moderado na qualidade de vida, e a presença de diabetes não ocasionou um pior impacto nesse parâmetro. Além disso, a presença de ansiedade foi mais prevalente entre os não diabéticos e pode ter refletido na pior pontuação no DHI observada nesse grupo.

Introduction: quality of life refers to an individual's perception of their physical, emotional, and social status, and it can be affected by conditions such as vestibular migraine and diabetes mellitus (DM). Objective: to describe the quality of life of patients with vestibular migraine, with and without DM. Methodology: this cross-sectional, descriptive, retrospective study conducted a secondary analysis of data collected from patients with vestibular migraine treated at a school clinic in Salvador-BA. Sociodemographic and clinical data were collected, including self-reported DM. Quality of life was assessed using the Dizziness Handicap Inventory (DHI), with scores used to classify the degree of impact of the disability as "mild" (0 to 30 points); "moderate" (31 to 60 points) and "severe" (61­100 points). Descriptive statistics were computed using simple and absolute frequency, or measures of central tendency and dispersion. Results: the sample consisted of 41 individuals, with a mean age of 42.46 years (SD = 13.83 years), who were predominantly female (87.80%), with diabetes (51.21%) and anxiety (58.54%), and without depression (90.24%). The mean DHI score was 47.26 (SD = 21.81), classified as moderate impact, and it was higher among non-diabetics. Anxiety was more prevalent among non-diabetics (60.00%). Conclusions: patients with vestibular migraine showed moderate loss of quality of life, and the presence of diabetes did not reflect a worse impact on this parameter. Anxiety was more prevalent among non-diabetics, which may explain why this group had the worst DHI score.

Characteristics of Nystagmus during Attack of Vestibular Migraine / 대한평형의학회지

OBJECTIVES: The purpose of this study is to investigate characteristics of nystagmus during attacks of vestibular migraine (VM), and to find a distinct clinical feature compared to other migraine and peripheral vestibular disorders. METHODS: This study is a retrospective chart review of 82 patients satisfied with VM criteria, which is formulated by the new Bárány Society. Spontaneous and positional nystagmus provoked by various head positions were examined with video-nystagmography in all patients. Bithermal caloric test and cervical vestibular evoked myogenic potential test (cVEMP) were also performed. The direction and peak slow-phase velocity (SPV) of nystagmus, unilateral caloric weakness and interaural difference of cVEMP were analyzed. Control groups were lesion side in acute VN for nystagmus results and healthy side in the patients with benign paroxysmal positional vertigo of posterior semicircular canal for caloric and cVEMP results. Chi-square test and Mann-Whitney U-test were used for statistical analysis. RESULTS: During the acute attack, nystagmus was seen in 71.9% (59 of 82) of patients. Horizontal nystagmus was the predominant type. Peak SPV in VM patients was much slower than in the control group (2.37±1.73 °/sec vs. 17.05±12.69 °/sec, p<0.0001). There was no significant difference on the result of both caloric and cVEMP test, compared to those of control groups. CONCLUSION: Nystagmus with horizontal directions and low SPV was dominant form in the attack of VM. Close observation of nystagmus can be helpful to make a correct diagnosis and to understand the pathomechanism of vertigo in VM.

Genetics research on vestibular migraine / 中华耳鼻咽喉头颈外科杂志

The combination of vertigo, dizziness and balance disturbance with migraine is called vestibular migraine, which is frequently reported in clinical neurology. However, the exact pathophysiological mechanisms of vestibular migraine still remain unclear. Familial occurrence of VM has been reported, suggesting a genetic component. With the rapid development of molecular genetic technology in recent decades, the genetic research about vestibular migraine has become a hot topic. The outcomes of molecular genetic studies of vestibular migraine could benefit to unveil the mysterious causes of this disorder. The present review summarized the molecular genetic studies of vestibular migraine.

Chinese multidisciplinary expert consensus on assessment and management of vestibular migraine / 中华内科杂志

Vestibular migraine (VM) is a common disorder characterized by recurrent dizziness and/or vertigo,which involves a number of specialites and is easily misdiagnosed.The Stroke and Vertigo Association of Chinese Stroke Association and Vertigo Professional Committee of Neurology Branch of Chinese Physicians Association organized multi-disciplinary experts to discuss clinical issues of VM.The purpose of this consensus is to establish a standard framework for the diagnosis and management of VM in China.

Enfoque del paciente con vértigo / Approach to patients with vertigo

El vértigo es definido como la sensación de movimiento ilusorio del cuerpo o de los objetos que le rodean. Es una de las causas más comunes de consulta en los departamentos de emergencia, y 2 a 3% de la población mundial consulta anualmente por este síntoma. De acuerdo al compromiso vestibular en el oído interno o en el sistema nervioso central o ambos, puede clasificarse en vértigo periférico, central o de origen mixto, siendo la principal causa del periférico el vértigo posicional paroxístico benigno. La valoración semiológica y anamnesis es fundamental para el diagnóstico. En el examen físico inicial, la diferenciación de un vértigo de origen central de otro de origen periférico, puede realizarse mediante el análisis del nistagmo, la valoración del impulso cefálico y la desviación ocular, que se integran en un sistema denominado HINTS, por sus siglas en inglés (Head Impulse, Nystamus type, Test of Skew), y por la realización de pruebas que evalúen también la vía vestíbulo-cerebelosa. Además, la realización de una audiometría tonal, aumentaría la sensibilidad diagnóstica de 71 a 89% en la evaluación inicial. El diagnóstico apropiado es la base para el tratamiento y control de esta condición clínica en el mediano y largo plazo.

Vertigo is defined as an abnormal sensation of body motion or of its surrounding objects. It is a common chief complaint in emergency departments comprising 2 to 3% of these consultations worldwide. Vertigo is classified as peripheral or central, according to its origin, and can also be occasionally mixed, the most common cause of peripheral involvement being benign paroxysmal positional vertigo. The initial findings on clinical evaluation of patients are the clues for making a correct diagnosis. The differentiation between central and peripheral vertigo can be optimized by analysing nystagmus, by using the skew test and the head impulse test (HINTS), as also by performing the appropriate tests to evaluate the integrity of the vestibular-cerebellar pathway. In addition, tonal threshold audiometry could raise the diagnostic sensibility from 71 to 89% on initial approach. Appropriate diagnosis is the principal key for managing this clinical condition.

Actualización en la prevalencia de trastornos del equilibrio en pediatría / Update on the prevalence of balance disorders in pediatrics

Las alteraciones del equilibrio son una causa muy común de consulta en pacientes adultos pero mucho menos habitual en la población pediátrica. Cuando esta sintomatología aparece en los niños genera gran preocupación, tanto en los padres, como en los profesionales consultados. Objetivo: Exponer nuestra casuística en alteraciones del equilibrio en pacientes pediátricos y enunciar las patologías prevalentes dividiendo la muestra en grupos etarios. Materiales y Métodos: Se realizó un estudio retrospectivo, observacional, descriptivo y transversal. Se incluyeron pacientes entre 1 y 17 años que consultaron al servicio de otorrinolaringología de un Hospital Pediátrico de alta complejidad entre junio de 2014 y junio de 2017. Resultados: Se incluyeron en el estudio 247 pacientes entre 1 y 17 años; 123/247 (49%) niñas y 124/247 (51%) varones. La mediana de edad fue de 9 años. Los síntomas más frecuentes en la consulta fueron: vértigo (63/247); cefaleas (44/247) y la asociación de vértigo + cefaleas (43/247). Las patologías prevalentes fueron: cefaleas 55/247; cerebelitis aguda 30/247; vértigo paroxístico benigno de la Infancia 21/247; migraña vestibular 21/247. Conclusiones: Ante la presencia de un niño con alteraciones del equilibrio, es muy importante la historia clínica y un minucioso examen otoneurológico pensando en cada prueba qué área o sistema estamos evaluando y dónde estaría localizada la lesión (vía vestíbulo-ocular; vía vestíbulo-espinal, etc.). Es importante diferenciar, dado que es la causa de consulta más frecuente, que no todo paciente que presenta cefaleas y síntomas vestibulares asociados tiene como diagnóstico una migraña vestibular (AU)

Balance disorders are a common reason for consultation in adult patients but are much less frequent in children. When children present with these symptoms it causes great concern, both in the parents and in the professionals consulted. Objective: To present our series of pediatric patients with balance disturbance and to describe the different underlying disorders dividing the patients according to age. Material and methods: A retrospective, observational, descriptive and cross-sectional study was conducted. Patients between 1 and 17 years of age who consulted at the Department of Otolaryngology at a tertiary care hospital between June 2014 and June 2017 were included. Results: 247 patients between 1 and 17 years of age were included in the study; 123/247 (49%) girls and 124/247 (51%) males. Median age was 9 years. The most frequent symptoms at consultation were: Vertigo (63/247); Headaches (44/247), and an association of vertigo + headaches (43/247). The most common diagnosis were: headaches 55/247; acute cerebellitis 30/247; benign paroxysmal vertigo of childhood 21/247; vestibular migraine 21/247. Conclusions: In a child with a balance disorder, the diagnostic interview and a thorough oto-neurological examination are important considering what area or system is evaluated in each test and where the lesion may be located (vestibulo-ocular tract; vestibulo-spinal tract, etc.). Differentiation is important as, considering is the most frequent reason for consultation, not every patient who presents with headache associated with vestibular symptoms has vestibular migraine (AU)

Characteristic analysis of positional nystagmus in patients with vestibular migraine / 第二军医大学学报

Objective To analyze the characteristics of positional nystagmus in patients with vestibular migraine (VM) and to discuss its possible mechanism. Methods We retrospectively analyzed the types, intensities, and time of positional nystagmus recorded by video nystagmography during Dix-Hallpike and Roll-test in 14 patients with acute episode of VM and 16 patients with benign paroxysmal positional vertigo (HSC-BPPV). Results A mixture of geotropic, apogeotropic and downbeat components with a variable combination of each component and various types of positional nystagmus were identified in VM. There was no significant difference in the latencies or the duration of positional nystagmus between VM group and HSC-BPPV group (P>0. 05). The peak slow-phase velocities (SPVmax) in horizontal component of positional nystagmus was (11.4 ± 2.3) °/s in VM group, which was significantly lower than that in the HSC-BPPV group ([56.8±9.4] °/s, P = 0.001). Compared with HSC-BPPV group, the time needed for reaching the SPVmax (tm) was significantly longer in VM group ([18.1±2.0] vs [5.9±1.1] s, P<0. 001), and the rate of velocity change was significantly slower in VM group ([0.54 ± 0.14] vs [7. 21 ±1. 79] °/s2, P<0.001). The asymmetry ratio of the stronger to softer SPVmax in HSC-BPPV group was significantly higher than that in the VM group (P = 0. 02). Conclusion Abnormal central integration mechanism in VM may lead to discordant transmission of semicircular canal rotation information, resulting in mixed nystagmus components and flat nystagmus that appeared at multiple positional maneuver.

Vestibular migraine: clinical and epidemiological aspects / Migrânea vestibular: aspectos clínicos e epidemiológicos

ABSTRACT INTRODUCTION: Vestibular migraine (VM) is one of the most often common diagnoses in neurotology, but only recently has been recognized as a disease. OBJECTIVE: To analyze the clinical and epidemiological profile of patients with VM. METHODS: This was a retrospective, observational, and descriptive study, with analysis of patients' records from an outpatient VM clinic. RESULTS: 94.1% of patients were females and 5.9% were males. The mean age was 46.1 years; 65.6% of patients had had headache for a longer period than dizziness. A correlation was detected between VM symptoms and the menstrual period. 61.53% of patients had auditory symptoms, with tinnitus the most common, although tonal audiometry was normal in 68.51%. Vectoelectronystagmography was normal in 67.34%, 10.20% had hyporeflexia, and 22.44% had vestibular hyperreflexia. Electrophysiological assessment showed no abnormalities in most patients. Fasting plasma glucose and glycemic curve were normal in most patients, while the insulin curve was abnormal in 75%. 82% of individuals with MV showed abnormalities on the metabolism of carbohydrates. CONCLUSION: VM affects predominantly middle-aged women, with migraine headache representing the first symptom, several years before vertigo. Physical, auditory, and vestibular evaluations are usually normal. The most frequent vestibular abnormality was hyperreflexia. Most individuals showed abnormality related to carbohydrate metabolism.

Resumo Introdução: Migrânea vestibular (MV) corresponde a um dos mais frequentes diagnósticos em otoneurologia, o que justifica a importância de seu estudo, embora tenha sido apenas recentemente reconhecida como entidade nosológica. Objetivo: Analisar os perfis clínico e epidemiológico dos pacientes atendidos em um ambulatório de migrânea vestibular. Método: Estudo retrospectivo, observacional e descritivo, com análise de prontuários dos pacientes do ambulatório de MV. Resultados: O ambulatório é composto por 94,1% de mulheres e 5,9% de homens, com média de idade 46,1 anos. O tempo de cefaleia foi superior ao de vertigem em 65,6% dos pacientes. Observou-se correlação entre os sintomas e o período menstrual. A maioria (61,53%) dos indivíduos apresentou algum sintoma auditivo, sendo o zumbido o mais frequente, embora a audiometria tenha sido normal em 68,51%. A vectoeletronistagmografia apresentou-se normal em 67,34%, enquanto 10,20% apresentaram hiporreflexia e 22,44% hiperreflexia vestibular. Exames eletrofisiológicos não mostraram alterações na maioria dos pacientes. Glicemia dejejum e curva glicêmica foram normais para a maioria dos pacientes, enquanto a curva insulinêmica mostrou-se alterada em 75% dos indivíduos. 82% dos indivíduos com MV apresentaram alguma alteração relativa ao metabolismo dos carboidratos. Conclusão: Migrânea vestibular acomete, predominantemente, mulheres de meia idade, com cefaleia migranosa e vertigem, sendo a primeira de instalação mais precoce. O exame físico no período intercrise, bem como as avaliações auditiva e vestibular, mostram-se, geralmente, normais. O tipo de alteração vestibular mais observado foi a hiperreflexia labiríntica. A maioria os indivíduos avaliados apresentou alterações relativas ao metabolismo dos carboidratos.

Vestibular migraine: diagnosis challenges and need for targeted treatment / Migrânea vestibular: desafios diagnósticos e a necessidade de tratamentos específicos

ABSTRACT Approximately 1% of the general population suffers from vestibular migraine. Despite the recently published diagnostic criteria, it is still underdiagnosed condition. The exact neural mechanisms of vestibular migraine are still unclear, but the variability of symptoms and clinical findings both during and between attacks suggests an important interaction between trigeminal and vestibular systems. Vestibular migraine often begins several years after typical migraine and has a variable clinical presentation. In vestibular migraine patients, the neurological and neurotological examination is mostly normal and the diagnosis will be based in the patient clinical history. Treatment trials that specialize on vestibular migraine are scarce and therapeutic recommendations are based on migraine guidelines. Controlled studies on the efficacy of pharmacologic interventions in the treatment of vestibular migraine should be performed.

RESUMO Cerca de 1% da população apresentam o diagnóstico de migrânea vestibular. Apesar dos critérios diagnósticos terem sido publicados recentemente, ainda é uma condição subdiagnosticada. Os mecanismos neurais exatos da migrânea vestibular ainda não estão claros, mas a variabilidade dos sintomas e achados clínicos durante e entre os ataques sugere uma interação importante entre os sistemas trigeminal e vestibular. A migrânea vestibular geralmente começa alguns anos após a migrânea típica e tem apresentação clínica variável. Em pacientes com migrânea vestibular, o exame neurológico e otoneurológico são geralmente normais e o diagnóstico é baseado na história clínica do paciente. Estudos sobre tratamento da migrânea vestibular são escassos e recomendações terapêuticas são baseadas em diretrizes do tratamento da migrânea. Estudos controlados sobre a eficácia das intervenções farmacológicas para o tratamento da migrânea vestibular devem ser realizados.

Can Nitroglycerin Differentiate Benign Recurrent Vertigo From Vestibular Migraine? A Preliminary Study / 대한평형의학회지

BACKGROUND AND OBJECTIVES: Nitroglycerin (NTG), a donor of nitric oxide, is known to provoke migraine attacks in patients with migraine. However, this effect was not explored in patients with benign recurrent vertigo (BRV). To infer the mechanism of BRV, we evaluated provocative effects of NTG in patients with vestibular migraine (VM) and BRV compared with normal controls. MATERIALS AND METHODS: Thirteen patients with recurrent vertigo, 8 with VM and 5 with BRV, and 5 healthy controls received intravenous infusion of 0.5 microg/kg/min NTG over 20 minutes. Headache intensity (visual analog scale) and associated symptoms were recorded at baseline and every 10 minutes for an hour. And the subjects were also asked to complete a headache diary every hour for another 12 hours. RESULTS: In contrast to normal controls (2/5, 40%, p=0.035) and the patients with BRV (1/5, 20%, p=0.007), all patients with VM (8/8, 100%) had migraine attacks after NTG injection. However, there was no difference in the proportion of the patients with migraine attacks after NTG injection between normal controls and the patients with BRV. CONCLUSION: In contrast to the patients with VM, patients with BRV are not sensitive to nitric oxide. These results suggest that the pathophysiology of BRV may be different from that of VM.