What We Treat - Migraine Associated Dizziness (MAD) and Migraine Associated Vertigo (MAV)
Dizziness associated with Migraine is an evolving diagnosis, not necessarily accepted by many members of the neurology community who more commonly limit the term, "Migraine," to symptoms with headaches with features characteristic for migraine headaches. Migraine Associated Dizziness is a diagnostic entity that does not require concurrent headaches as part of the symptom complex for diagnosis. Those of us who treat dizziness and vertigo have begun to appreciate that migraine and dizziness can present with a variety of symptoms. This entity (MAD) is gaining a foothold in the medical literature. Since there is no definitive diagnostic test for Migraine as a cause of dizziness/vertigo, this diagnosis can be difficult to differentiate from other entities associated with dizziness/vertigo. Moreover, some patients with Meniere's disease can suffer from migraine, which can also sometimes make an accurate diagnosis difficult.
Migraine occurs in about 13% of the adult population in the United States. While a small percentage of people with migraine have vertigo/dizziness, Migraine Associated Dizziness is most likely the cause of more dizziness than any other condition. In contrast Meniere's disease only affects 0.2% of the US population. Other inner ear problems, such as Benign Paroxysmal Positional Vertigo or Meniere's disease can occur more frequently in patients with migraine. The majority of cases of migraine occur in women with the highest incidence during childbearing age, followed by an abrupt decline with menopause.
The etiology of Migraine Associated Dizziness is unknown. Some have suggested that is an inappropriate sensory amplification of or failure to regulate the sensory feedback signals to the brain resulting in analogous sensation of pain or sensory overload. For example, patients with migraine can perceive sounds as painful (hyperacusis, phonophobia), have sensitivity to light (photophobia), have allodynia (pain from stimuli not painful to most other people), dizziness with changes in the weather, or disruptive dizziness to routine motion or head movements. Any or all of these symptoms except for dizziness are not required for diagnosis of migraine associated dizziness. Nevertheless, they are helpful for such diagnosis.
Other information have suggested that migraine may be due to:
- vasospasm in blood vessels in certain areas of brain tissue involved with balance;
- biochemical neurotransmitters in areas of the peripheral or balance system areas of the brain/central nervous system or
- disturbances in calcium channel metabolism in the balance system of the brain/central nervous system and inner ear.
Migraine associated dizziness can present with a myriad of symptoms along with vestibular disturbances. Classically, the patient has a prior history of migraine headaches, family history of headaches, motion sickness during childhood, and the vertigo is a rocking sensation lasting a few hours. Other variable symptoms are:
- aural fullness, pressure
- tinnitus, (ear noises)
- otalgia (ear pain)
- nausea and/or emesis
- sensitivity to light (photophobia)
- sensitivity to sounds (phonphobia)
- blurred vision, visual changes, shimmering of parts of the visual field
- facial or finger tingling (pareathesias)
- facial numbness
- difficulty talking (dysarthria)
- spaced out, fogginess feeling, inability to concentrate
- sensitivity to positional changes
- baseline unsteadiness.
Unilateral hearing loss is uncommon with Migraine associated dizziness.
In some ways, the diagnosis of Migraine associated dizziness (MAD) is a diagnosis of exclusion, because many other causes of dizziness need to be ruled out. As a minimum, a detailed otologic-neurotological history, physical examination, and audiometric testing will be the first step. Laboratory tests, vestibular testing, imaging studies, and possible neurology, optometric, rheumatology (autoimmune disease) consultations may be requested.
Treatment of MAD
The treatment of migraine associated dizziness is with a migraine prophylaxis (prevention) protocol for successful management of dizziness in contrast to acute management for migraine headaches. Avoidance of dietary triggers such as caffeine, coffee, chocolate, red wine, alcohol, certain cheeses, and other foods are required. Please see Migraine Prophylaxis Diet Sheet.
Medication therapy will vary based upon your response. Usually, migraine prophylaxis commences with any of the following: topiramate (topamax), or, an antiseizure medication, or beta blockers (propranolol, metoprolol), or Calcium channel blockers (verapamil, flunarizine). Other medications may be utilized as needed until the appropriate treatment is established.
1Timothy C. Hain, MD, http//www.dizziness-and-balance.com/disorders/central/migraine/mav.html