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Symptoms of a vestibular migraine

Dizziness due to migraine is quite common; the diagnosis is based on the patient’s story as there are no clinical findings except when the patient is having an attack and there is no blood test or scan that can make the diagnosis.

In about a fifth of patients, their first experience is that of visual abnormalities. Examples of patients' complaints include:

  • zigzagging lines or flashing lights
  • numbness and tingling of parts of the body
  • difficulty speaking 

These last from between five minutes to an hour, and then resolve. They are then followed by a dizzy sensation of spinning rather than feeling intoxicated.

The dizziness can last from a few seconds to days but is typically between five minutes and three days.

Figure showing the vestibular system

Most patients experience nausea, and over half experience unpleasant sensitivity to sound and light (photophobia) and/or one-sided pulsing headaches with a desire to lie down in a darkened room 

In about a third of patients report that ringing in their ears ('tinnitus') is experienced.

Triggers

Attacks may be triggered by:

  • foods (e.g. dark chocolate)
  • menstrual periods
  • stress
  • lack of sleep
  • glyceryl trinitrate (GTN)
  • histamine
  • ranitidine
  • hormone replacement therapy (HRT)
  • caffeine
  • exercise
  • computer use
  • watching films
  • flashing lights

Between attacks patients describe  motion sickness and dislike of strong or flashing lights or loud sounds. Often the patient has a history of migraine (or family history of migraine), motion intolerance.

Diagnosis

Vestibular migraine is associated with Méniere’s Disease, benign positional paroxysmal vertigo or Persistent Postural-Perceptual Dizziness (PPPD) so the diagnosis can be quite complicated.

Examination

There are no abnormal findings except during an attack.

Treatment

The migraine headache can be treated with an escalation of the following medicine, (depending on response) however the vertigo symptom is less responsive to medications. 

  • Paracetamol (1 or 2 x 500mg tablets every four to six hours but the patient should not take more than 4g (8 x 500mg tablets) in the space of 24 hours.

or

  • Ibuprofen one or two 200mg tablets every four to six hours, but no more than 1,200mg (six 200mg) tablets in the space of 24 hours

or 

  • Rizatriptan benzoate 10mg (Maxalt Malt) ASAP on onset of symptoms then 10mg after two hours (if there is no response, increase to a maximum dose of  20mg per day).  

or

  • A combination of a Triptan + Paracetamol; or Triptan + Ibuprofen
     

The nausea can be treated with Buccastem (prochlorperazine maleate) 3mg bd buccal tablet for no more than two days.

Prevention of vestibular migraine attacks

Patients that have migraine attacks that are causing frequent disability (for example, two or more attacks per month that last for three days or more) in which standard analgesia and triptans are either contraindicated or ineffective can be offered preventative treatment.

This usually is either amitriptyline or propranolol.

Propranolol is suitable for people with coexisting hypertension or anxiety, however, is not suitable for people with asthma, chronic obstructive pulmonary disease, peripheral vascular disease, or uncontrolled heart failure.

Amitriptyline, 10 mg at night, incrementing to 20 mg after two weeks, is useful in patients with features of low mood.

If these do not work, then topiramate may be considered, but treatment is more complex due to potential side effects.

In particular women of childbearing potential need to be advised that topiramate is associated with a risk of fetal malformations and can impair the effectiveness of hormonal contraceptives. 

It can also be associated with short lived paresthesia in arms and legs in the first few days. The maximum dose is 50mg BD as cognitive side-effects creep in beyond this.

If the patient is at risk of renal stones this drug will increase the risks by 1 in 100.

Treatment cost

The London Clinic offers affordable, competitive self-pay packages for certain treatments.

Patients have the option to spread the cost of treatment with Chrysalis Finance.

Please call +44 (0)20 3613 7502 to speak to our helpful team to find out more and to book an appointment.

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