Migraine induced vertigo also known as migrainous vertigo, vertiginous migraines, or migraine associated disequilibrium refers to an extremely common, poorly understood, and most times misdiagnosed condition. This condition is most likely common manifestation of variety of disorders. The reason they are all put into one category is that they commonly mimic symptoms of migraines and respond to similar treatments. There is currently no consensus in terminology, definition, or treatment of these disorders. Considering that approximately ¼ of woman in the United States and approximately 10% of men suffer from migraines, vertigo associated with migraines is quite common. Since the vertigo attacks in these patients usually presents without headaches are commonly misdiagnosed as BPPV or Ménière’s disease.
The symptoms could extend anywhere from head fogginess and feeling that the person is constantly on a boat to severe relentless vertigo lasting hours and days at a time. In selected individuals they are accompanied by aura such as visual disturbances, commonly blurry vision or seeing bright or black spots in the field-of-view. They could however present with ear pressure or sinus pressure and hence misdiagnosed as ear infection, Ménière’s disease, or chronic sinus disease.
Unfortunately at this time there are no objective methods of diagnosing this condition such as hearing tests or MRI scans. However the clinical presentation is nearly always sufficient to make this diagnosis.
Similar to migraines the most important treatment is avoiding the triggers. The common triggers for this condition are quite similar to the triggers known for migraine disorder. They could be classified as a following:
- Dietary: This includes caffeine, chocolate, red wine, alcohol, aged cheese, artificial sweeteners, artificial dyes, MSG, salt and many other additives.
- Allergies: If allergies are the trigger, patients with have this migraine vertigo attacks mostly during the allergy season.
- Stress, anxiety, and poor sleep: This is probably the most common nondietary trigger and most commonly the most difficult one to treat.
Dr. Monfared also recommends an MRI of the internal auditory canal and brain with and without contrast to rule out presence of intracranial pathology that can mimic this process. At times intracranial hypertension also known as pseudotumor as well as other intracranial disorders can mimic this condition.
Many patients are managed with conservative therapy which includes avoidance of triggers, use of supplements such as magnesium and fish oil. When this fails they are referred to neurology for migraine management. These patients in most cases unfortunately do not respond to usual migraine medications such as triptans. The most commonly used medications for these patients include magnesium, nortriptyline, calcium channel blockers, or beta-blockers.
Vestibular rehabilitation is also very important but has to wait to the patient’s acute vertigo attacks have resolved. In our experience patients would’ve been suffering from chronic dysequilibrium due to migraines cannot tolerate vestibular exercises until they no longer experience dysequilibrium. Once this has achieved through medication and avoidance of triggers, slowly progressing but intense vestibular therapy could be started.