Vertigo

Vertigo

1. Interesting Case Presentation Done by: Dr.Nabila Ahmed Al- Balushi Family Medicine R4

2. T.Z. is 40 yrs old gentleman Attending the LHC with a complain of rotational feeling of the surrounding which is worse for the last 2 weeks.

3. The symptoms started first 8 yrs back. Initially he will get one episode per 2-3 months Description of an episode: sensation of rotational feeling of the surrounding, will not be able to balance during walking, sometimes has numbness of the LL. May be associated with nausea and vomiting The episode may last 1-2 hrs. the patient will sleep when the symptoms start and feels better when he wakes up.

4. Recently the frequency of the episodes started to increase  Almost every week Last Week the episodes of vertigo are happening every day And symptoms are not resolving even after sleep.

5. Symptoms are present at rest, feeling of imbalance during walking No headache or visual complains No hearing problems , no tinnitus, no ear discharge No h/o fever No h/o recent viral URI No h/o head injury

6. Past Medical History: Uremarkable apart from episodes of vertigo Surgical history: nil Allergies: nil Family history: f/h/o migrain headache in sibling Social History : Married with children, working as a clerk Non smoker or alcohol consumer The symptoms of vertigo has significantly affected his lifestyle, esp over the last 2 weeks

7. Patient attended ENT clinic at tertiary care center and was started on betahistine but no improvement in his symptoms

8. Because his symptoms didn’t improve, he attended A/E at Royal Hospital were CT brain was done and it ruled out acute insult to the brain

9. Patient was referred from the LHC to ENT Al- Nahdah hospital for further evaluation .

10. ENT examination: Otoscopy : TM clear b/l , no ear discharge Dix Hallipike test – ve No nystagmaus

11. The patient was referred back to the local health center, advised referral to Khoula Hospital Neurology with impression of …

12. Vestibular M igraine

13. Vestibular migraine represents the second most common cause of vertigo after benign positional vertigo by far exceeding Menière’s disease

14. The manifestations of vestibular vertigo may include:  episodic true vertigo positional vertigo constant imbalance movement-associated dysequilibrium , and/or lightheadedness.  

15. Symptoms can occur before the onset of headache, during a headache, or during a headache-free interval. Many patients who experience migraine  have vertigo or dizziness as the main symptom rather than headache.

16. Episodic vertigo occurs in about 25-35% of all migraine patients. Epidemiology Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence. A review of population-based studies.  Neurology . 1994 Jun. 44(6 Suppl 4):S17-23. 

17. A Turkish study of 100 children with vertigo who presented to a pediatric neurology referral center found that migraine-associated vertigo was the fourth most common form of the condition (11%) Batu ED, Anlar B, Topcu M, et al. Vertigo in childhood: a retrospective series of 100 children .   Eur J Paediatr Neurol . 2015 Mar. 19(2):226-32.

18. The etiology of migraine-associated vertigo is not completely understood.  Migraine headache and migraine-associated vertigo are often triggered by certain factors, including stress, anxiety, hypoglycemia, fluctuating estrogen, certain foods, and smoking. Pathophysiology

19. Commonly accepted theory regarding the pathophysiology of migraine-associated vertigo Episodes of dizziness of a duration similar to that of a migraine aura (< 60min) that are time-locked with the headache most likely have the same pathophysiologic mechanism Pathophysiology: Spreading depression theory

20. According to the spreading depression theory, some type of stimulus ( eg , chemical, mechanical) results in a transient wave front that suppresses central neuronal activity. This depression spreads in all directions from its site of origin. Neuronal depression is accompanied by large ion fluxes, including increases in extracellular potassium (K + ) and decreases in extracellular calcium ( Ca ++ ). These changes result in a reduction in cerebral blood flow in the areas of spreading depression. Spreading depression theory

21. A varied range of dizzy symptoms even within individual attacks.   These symptoms may be solitary or may be a combination of vertigo, lightheadedness, and imbalance . A thorough headache history is also important  History

22. Dizziness symptoms present for a few weeks or for several years . Vertigo may occur spontaneously, provoked by head motion or by visual stimuli. Symptoms may last for a few minutes or may be continuous for several weeks or months . In women, dizziness may often occur during the menstrual cycle. History

23. Patients with migraine-associated vertigo often provide a long history of motion intolerance during car, boat, or air travel Vertigo is the most common type of dizziness reported, and it is present at some time in approximately 70% of patients. History

24. Most patients have dizziness symptoms during headache-free intervals or even numerous years following their last migraine headache.   Some patients with migraine-associated vertigo have never experienced a migraine headache but have a family history of migraine. History

25. Findings on a complete neurologic examination are often normal. Horizontal rotary spontaneous nystagmus may be present during an acute attack of vertigo. Physical findings

26. No diagnostic tests exist for migraine-associated vertigo. history is the most important means to diagnose this condition.   When the history is unclear, the diagnosis is made by a therapeutic response to treatment . Diagnostic Criteria

27. Proposed criteria for the diagnosis of probable migraine-associated vertigo include the following: Episodic vestibular symptoms of at least moderate severity - Rotational vertigo, other illusory self or object motion, positional vertigo, head motion intolerance At least 1 of the following: Migraine according to the criteria of the IHS, Migrainous symptoms during vertigo Migraine-specific precipitants of vertigo ( eg , specific foods, sleep irregularities, hormonal changes ) response to antimigraine drugs Other causes ruled out by appropriate investigations Proposed Diagnostic Criteria

28. Peripheral vestibular disorders include the following : Ménière disease Perilymphatic fistula Benign paroxysmal positional vertigo Recurrent vestibular neuritis Recurrent vestibulopathy Central vestibular disorders include the following : Multiple sclerosis Central paroxysmal positional vertigo Vertebrobasilar artery insufficiency Cervicomedullary compression from abnormalities of the craniovertebral junction Differentials

29. Differential Diagnosis

30. Abortive medications for acute attack Prophylactic medical therapy . Treatment

31. The first step should always be to give the patient a diagnosis and for the patient to accept this diagnosis.  Rare and long vestibular spells would call for rescue medication only / frequent and/or short episodes would require a prophylactic approach . It is important to consider comorbidities, such as arterial hypertension or hypotension, anxiety and depression, asthma and body weight establish if vertigo and headaches are equally distressing or whether one is more pronounced than the other.

32. General recommendations for migraine headache prophylaxis, such as diet , sleep hygiene , avoidance of trigger factors , are probably also beneficial for migrainous vertigo Biofeedback methods have been reported for other kinds of equilibrium problems or vertigo but to date such studies have not been reported for vestibular migraine Nonpharmacological measures

33. The duration of individual attacks of vestibular migraine varies widely from seconds to weeks, but mostly they last from minutes to hours In the case of prolonged attacks, a symptomatic rescue treatment could be considered. Treatment of the individual attack

34. Acute antivertiginous and antiemetic drugs are considered useful for suppressing vestibular symptoms such as  promethazine 25 or 50 mg which combines antivertiginous , antiemetic and sedating properties  metoclopramide which helps to control the nausea and vomiting associated with both headache and vertigo  Antihistaminic drugs such as dimenhydrinate and meclizine are useful for treating milder episodes of vertigo and for controlling motion sickness. National Center for Biotechnology Information, U.S. Ther Adv Neurol Disord . 2011 May; 4(3): 183–191. Management of vestibular migraine Alexandre R. Bisdorff

35. In a retrospective study based on patient records, sumatriptan was found to be efficient when the vestibular symptoms were linked or not linked to the headache.   If individual attacks need to be treated it would be safer to use a generic strategy with symptomatic drugs to relieve vertigo and nausea, as in other causes of acute vertigo Are there any specific treatments for vertigo attacks of migrainous origin?

36. If quick relief is needed, a calcium antagonist ( flunarizine or verapamil) in the case of prolonged treatment, watch out for extrapyramidal side effects and depression for flunarizine . When there is coexisting hypertension , a betablocker should be considered if bronchospasm or bradycardia is not a problem . If headaches are prominent consider the anticonvulsant topiramate in obese patients and valproate in nonobese patients,

37. When there is coexisting s leep disturbance and anxiety consider amitryptiline or nortryptiline . If psychiatric symptoms are prominent, benzodiazepines , SSRI and/or a referral to a psychiatrist or behavioural therapist should be considered. If headache is rare compared with vertigo and/or the vertigo is part of an aura , lamotrigine could be given as first choice .

38. Acetazolamide is a potentially interesting drug for vestibular migraine. So far this drug has mainly been observed to be highly effective for episodic ataxia and a familial syndrome of migraine, vertigo and tremor .

39. Referral to vestibular rehabilitation should be considered for all patients, particularly if secondary complications such as deconditioning, loss of confidence in balance or visual dependence have developed

40. Thank You

41. National Center for Biotechnology Information, U.S. Ther Adv Neurol Disord . 2011 May; 4(3): 183–191.Management of vestibular migraineAlexandre R. Bisdorff Migraine-Associated Vertigo, Mar 09, 2017  , Author : Aaron G Benson, MD; Chief Editor: Arlen D Meyers, MD, MBA   References