Vestibular system testing in patients with migrainous vertigo
Patrick Sparto, PhD,1 Dawn A. Marcus, MD,2 Michael J. Soso, MD, PhD,3
Joseph M. Furman, MD, PhD3
University of Pittsburgh Medical Center
Departments of Otolaryngology,1 Anesthesiology,2 & Neurology3
Pittsburgh, PA
Acknowledgement: Supported by grants from the National Headache Foundation, Merck & Company, the Eye and Ear Foundation, and the Raymond & Elizabeth Bloch Charitable and Educational Foundation
Introduction
Balance symptoms are increasingly recognized as important and disabling symptoms for some migraineurs. Patients with a primary complaint of either migraine or vestibular disorder have a greater than expected prevalence of the other disorder. In patients with a primary complaint of migraine, dizziness occurs in 28% to 30% and true vertigo in 25% to 26%.[1][2] A survey of 659 migraineurs aged 15 to 19 years identified concomitant dizziness in 237 (36%).[3] Migraine was identified in 38% of 200 consecutive patients referred with the primary complaint of dizziness, compared with a 24% migraine prevalence in a comparison group of orthopedic patients.[4] A similar study evaluating migraine in patients with isolated vertigo (N=72) vs. orthopedic controls identified migraine in 61% of patients with vertigo, but only 10% of orthopedic patients.[5]
Neuhauser, et al. recently established specific diagnostic criteria for the determination of migrainous vertigo.4 We recently developed and published a structured interview to incorporate these criteria into the evaluation of migrainous vertigo.[6] Utilization of these criteria permits more standardized patient diagnostic classification.
Methods
Adults with migraine and age- and sex-matched controls were evaluated with optic flow and posturography testing. Optic flow testing included exposure to 8 different optic flow stimuli that each translated sinusoidally 16 cm (peak to peak) in the anterior-posterior (AP) direction including: 2 frequencies (0.1 and 0.25 Hz), 2 visual patterns (checks and stripes), and 2 sizes of visual pattern (small and large). Amount (root-mean-square) of AP head sway was measured during each stimulus condition. (See Figure 1.) Posturography was performed using the Sensory Organization Test (Neurocom, Inc.).
Comparisons were made among 3 subject groups: 5 migraineurs without vertigo (4 females & 1 male; mean 31yrs), 5 migraineurs with migrainous vertigo (4 females & 1 male; mean 34yrs), and 4 non-headache controls (3 females & 1 male; mean 28yrs).
Results
During optic flow testing, there were no differences in exposure to any of the individual variables within the 8 stimulus conditions. Therefore, a comparative evaluation was made for the mean sway of all 8 conditions among the three subject groups. Mean head sway was numerically greater for the group with migrainous vertigo (0.48 ± 0.46 cm) compared with migraine without vertigo (0.22 ± 0.13 cm) or controls (0.29 ± 0.15 cm). (See Figure 2.) This difference was not statistically significant (P = 0.13) because of the variance in head sway with one outlier within the migraine with vertigo group.
Posturography Equitest composite scores were lower (P=0.06) in subjects with migraine with vertigo (72.6) compared with migraine without vertigo (80.4) or controls (80.6). (See Figure 3.) Equitest scores were significantly lower in migraine without vertigo, during conditions 4 (P=0.05) and 6 (P=0.04).
Conclusions
Although preliminary, data from visually-induced sway on optic flow testing suggests increased reliance on visual cues in people with migrainous vertigo. Reduced performance on conditions 4 and 6 during posturography indicates increased dependence on somatosensory cues for balance in people with migrainous vertigo. These data suggest that people with migrainous vertigo have an alteration in vestibulo-spinal functions.
References
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[3] Split W, Neuman W. Epidemiology of migraine among students from randomly selected secondary schools in Lodz. Headache 39(7), 494-501 (1999).
[4] Neuhauser H, Leopold M, von Brevern M et al. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 56(4),436-441 (2001).
[5] Lee H, Sohn SI, Jung DK et al. Migraine and isolated recurrent vertigo of unknown cause. Neurol Res 24(7), 663-5 (2002).
[6]Furman JM, Marcus DA, Balaban CD. Migrainous vertigo: development of a pathogenetic model and structural diagnostic interview. Current Opinion Neurology 2003; 16:5-13.