Vestibular Migraine Patient information leaflet I wrote for MTW NHS Trust

Vestibular Migraines

(Migraine associated vertigo, definite/probable migrainous vertigo, benign paroxysmal vertigo of childhood).

Your doctor suspects your symptoms may be due to vestibular migraines. These are the most common cause of recurrent spontaneous vertigo. They can occur at any age but typically in early mid-life. They are 3 times more common in women and often there is a positive family history or past personal history of migraines. Those with motion sickness have an increased susceptibility to vestibular migraines.

How do they present?

Attacks of vertigo, head motion discomfort or rocking sensation of variable duration accompanied by migrainous symptoms such as: headache (though not necessarily), light, sound or motion sensitivity, or auras (altered vision or sensation). Other symptoms include: head or ear pressure, sinus pressure, allergy headaches or pressure or pain in the neck. Diarrhoea can also be present. Sometimes the attacks are triggered by certain foods, lack of sleep, poor neck posture, stress, weather, hormonal changes (such as occurring in association with the menstrual cycle), strong smells, or allergies. After the vertigo has settled, people usually feel very tired, often with a strong urge to lie in a dark room.

What causes them?

They are not fully understood, but theories include: abnormal/overly sensitive processing of normal balance input, altered thalamic modulation, ion channel dysfunction, neurotransmitter imbalance, a wave of spreading electrical activity, blood vessel spasm and relaxation, and secretion of inflammatory neuropeptides.

Diagnosis

This depends on your symptoms as examination and investigations are usually normal. There are no tests that can confirm the diagnosis. Your doctor may arrange a hearing test, an MRI scan or special balance tests to rule out other causes for your symptoms.

Management

Lifestyle

Regular sleep, regular snacks (avoid missing meals), reducing stress, drinking plenty of water throughout the day, and taking regular exercise (reduces stress and improves sleep) are really important to reduce your attacks. Keep a diary of symptoms, perhaps with a migraine app on your phone - this will help you identify triggers, monitor symptoms and measure treatment effect.

Reduce known food triggers

Avoiding the following may help reduce your vertigo.

1) Foods that contain complex products of food aging and fermentation e.g. wines, aged cheeses, fresh baked bread, yoghurt.

2) Foods that contain chemicals that stimulate the brain e.g. caffeine, chocolate, tyramine in aged cheese/beers/smoked meats or fish, monosodium glutamate (MSG).

3) Others e.g. peanuts, banana, citrus fruits.

There is a 16% success with caffeine cessation alone. Riboflavin (400mg once daily), Magnesium (600mg once daily) and Coenzyme Q10 (100mg three times a day) supplements are also advised.

Medications

If lifestyle and dietary changes do not control your symptoms, medications can be tried.

During an acute attack

Drinking 2 pints of water, taking Paracetamol, Cinnarizine, or Aspirin/Ibuprofen/Naproxen. Vestibular sedatives are only helpful in 20%, but sublingual Prochlorperazine may be beneficial. This should be used sparingly. Your doctor may prescribe this if your attacks are infrequent. The Triptan class of drugs are only effective against headaches.

Preventative

These are useful and effective in those with frequent or severe symptoms that warrant daily preventive medication. Examples that your doctor may prescribe include antidepressants, beta-blockers, anticonvulsants, or calcium channel blockers. The choice of medicine is dependent on your coexisting medical conditions and side effect profile. If your symptoms started with taking the combined contraceptive, changing to a progesterone only version may help.

Sometimes finding the right treatment for you is a process of trial and error. Wait 8 weeks to see the full effect of any treatment (unless you are suffering unbearable side effects). You may need a high dose for a long time. A 50% reduction in your symptoms is a good result. The treatment course is usually for 6 months after which your medication dose can slowly be reduced. Your doctor will advise on the best way to do this.

Your doctor may also refer you to the physiotherapy department for vestibular rehabilitation, which has a proven benefit for most forms of dizziness.