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Migraine Associated Recurrent Vertigo

Migraine Associated Recurrent Vertigo

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The relationship between migraine and vertigo is well known. Migraine patients may suffer different types of vertigo: Meniere disease,
basilar-type migraine with vertigo as an aura, benign positional vertigo and migraine associated recurrent vertigo (MARV). MARV is one of
the most prevalent vertigo in migraine patients, included as a common cause of recurrent spontaneous vertigo in the neurotological literature.
MARV is an entity with its own clinical pattern, pathophysiology and treatment. Differential diagnosis should be done with benign
positional vertigo, Meniere disease and basilar type migraine. Specific diagnosis criteria could help in its recognition and management.
The relationship between migraine and vertigo is well known. Migraine patients may suffer different types of vertigo: Meniere disease,
basilar-type migraine with vertigo as an aura, benign positional vertigo and migraine associated recurrent vertigo (MARV). MARV is one of
the most prevalent vertigo in migraine patients, included as a common cause of recurrent spontaneous vertigo in the neurotological literature.
MARV is an entity with its own clinical pattern, pathophysiology and treatment. Differential diagnosis should be done with benign
positional vertigo, Meniere disease and basilar type migraine. Specific diagnosis criteria could help in its recognition and management.

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JOURNAL OF NEUROLOGY AND NEUROSCIENCE
iMedPub Journals
2010Vol.1No. 1:2
doi: 10:3823/301
Migraine associated recurrent vertigo
Jesús Porta-Etessam MD
Neurology Department. Hospital Clínico Universitario San Carlos. Madrid.Correspondence:Jesús Porta-Etessam. C/ Andrés Torrejón, 15, 7º. 28014 Madrid. Spain.E-mail jporta@yahoo.com, mporta@caminos.recol.es Phone: +34 667 062 4
Introduction:
 The International Classication o Headache Disorders is beco-ming the most important reerence document or the manage-ment o headache patients (1). Include several migraine relatedsymptoms or syndromes as migraine related seizure or cyclicvomiting syndrome, but not the migraine associated recurrentvertigo (MARV)? The relationship between vertigo and migraine is well-knownsince the initial description in 1873 (2). It has gone beyondthe scientic eld reaching the literature in the exciting JulioCortaza´s short tale titled “Cealea” (3). Although migraine pa-tients mayn suer dierent types o vertigo (table 1), MARV hasits own specic clinical eatures. It is the third cause o consul-tation or vertigo in a general neurology outpatient clinic (4)and is included as a common cause o recurrent spontaneousvertigo in the neurotological literature (5). MARV is an entitythat needs its own place in the International Classication o Headache Disorders.
Delimiting MARV:
MARV diers rom other vertigos present in migraine patientsand rom other types o recurrent vertigos. Most migraine pa-tients experience instability or poor balance sensation duringmigraine attacks. This multiactor symptom is not vertigo andit diers radically rom MARV, where patients suer motion illu-sion during the episodes.
© Under License o Creative Commons Attribution 3.0 License This article is available rom:http://www.jneuro.com
 The dierential diagnosis with benign positional vertigo (BPV),(6) a type o vertigo with an increased incidence in migrainepatients (possibly related with utriculus ischemia) (7-8) is ne-cessary. There are two critical dierences: MARV attacks lastor hours or even days opposed to BPV characterized by shortepisodes o vertigo lasting seconds or minutes; and BPV is apostural induced vertigo that may be induced by positional-provoked manoeuvres. The lack o auditory symptoms is crucial to distinguish MARVrom Meniere disease (MD). MD uses to have otological symp-toms during the attacks and in the late phase the patients de-velop a sensorineural deaness. An increase incidence o MD inmigraine patients has been reported. Even though a geneticrelationship between both entities or an induced mechanismby lowering the “clinical” threshold could justiy this association,it is dicult to explain it rom a pathophysiology or biologicalplausibility approach. It is possible that some MD patients weremisdiagnosed cases o MARV.MARV is not a basilar type migraine (BTM). The aura o BTM, ty-pically precede the migraine attack, opposed to MARV wherethere is not a temporal relationship with the migraine. Floridaura symptoms o BTM are lacking in MARV that may be also
The relationship between migraine and vertigo is well known. Migraine patients may suer dierent types o vertigo: Meniere disease,basilar-type migraine with vertigo as an aura, benign positional vertigo and migraine associated recurrent vertigo (MARV). MARV is one o the most prevalent vertigo in migraine patients, included as a common cause o recurrent spontaneous vertigo in the neurotological lite-rature. MARV is an entity with its own clinical pattern, pathophysiology and treatment. Dierential diagnosis should be done with benign positional vertigo, Meniere disease and basilar type migraine. Specifc diagnosis criteria could help in its recognition and management.
 Table 1. Types o vertigo in migraine patientsMigraine associated recurrent vertigoBasilar type migraineBenign positional vertigoMeniere diseaseBenign paroxysmal vertigo o the childhood
 
 
© Under License o Creative Commons Attribution 3.0 License This article is available rom:http://www.jneuro.com
JOURNAL OF NEUROLOGY AND NEUROSCIENCE
iMedPub Journals
2010Vol.1No. 1:2
doi: 10:3823/301
associated with migraine without aura (1). MARV not only di-ers rom BTM in the clinical spectrum but also in the longerduration o the vertigo attacks.Assuming the relevance o cortical spreading depression, andtrigeminal nociception in the pathophysiology o migraine, it’swell known the trigeminal innervations o the crista ampulla-ris, and there are cortical regions that projects to the brainstemvestibular complex (9-10). The release o neuropeptides intothe vestibular peripheral cells or in the vestibular nucleus couldprecipitate and maintain the vertigo. Even this neuropeptidescould sensitized the vestibular system and justiy the subclini-cal vestibular alteration shown in migraine patients (11). Otherexplanation o vertigo in migraine patients is the cortical sprea-ding depression. It has been described vertigo episodes as anepileptic symptom and vertigo is one o the eatures o BTM(1, 12). And nally both syndromes share some eatures: Are re-current and chronic, the episodes last rom hours to days, andboth could be the result o peripheral or/and central neuronalmechanisms.Neurons in lateral and medial vestibular nucleus respond to se-rotonin increasing the ring rate and autoradiographic studiesconrm the presence o 5-HT 1 and 5-HT2 receptors in the ratvestibular nucleus (13, 14). There are evidences about the par-ticipation o glutamate and calcitonin gene-related peptide inthe vestibular nerve bres (15). The presence o those receptorsand neurotransmitters bring nearer again migraine and MARV. There is some controversy about the peripheral or central ori-gin o MARV. The duration o the episodes lasting even dayswithout compensation, the lack o hypoacusia, ullness or tinni-tus and the improvement with triptans or migraine-preventivedrugs uphold the central-origin hypothesis.MARV responds to several migraine-preventive drugs (16-20). Topiramate seems to be an option reducing the requency o the vertigo attacks (18). Flunarizine has shown to be an eec-tive treatment or MARV (16-17). As a personal communicationvalproic acid also works well in these patients. Acetazolamidea drug eective in amilial hemiplegic migraine and episodicataxia type 2 may be also a useul option in both MARV and mi-graine with aura (11, 21). The vertigo attacks seem to respondto triptans (22).
Waking through the diagnostic criteria.
 Tables 2, 3 and 4 show the proposed diagnosis criteria dividedby denitive, probable and possible.
Conclusions
MARV is an entity that has its own clinical pattern, pathophysio-logy and treatment. Dierential diagnosis should be make withbenign positional vertigo, Meniere disease and basilar type mi-graine. Specic diagnosis criteria could help in its recognitionand management.
References
1) Headache Classication Subcommittee o the InternationalHeadache Society. The International Classication o HeadacheDisorders, 2nd ed. Cephalalgia 2004; 24 Suppl 1: 1-160.2) Kayan A, Hood JD. Neuro-otological maniestations o migra-ine. Brain 1984; 107: 1123–1142.3) Cortazar J. Cealea. En: Cortazar J. Cuentos completos. Ma-drid: Alaguara. 1994; 134-143.4) Porta-Etessam J, Martinez-Salio A, Berbel-García A, RamosA, Millán J, Garcia-Ramos R, Gonzalez-Martinez V. Evaluation o neuro-otology patients in a general neurology oce. Journal o Neurology 2003; 250 (SII): 105-106.5) Halmagyi GM, Baloh. Overview o common syndromes o vestibular disease. En: Baloh RW, Halmagyi GM (Eds) Disorderso the Vestibular System. Oxord 1996; 291-299.6) Porta-Etessam J, Martinez-Salio A, Villarejo A et al. Vértigo po-sicional paroxístico: Un síndrome para detectar, diagnosticar ysolucionar. Neurología 2004; 19: 495-496.7) Olsson JE. Neurotologic ndings in basilar migraine. Laryn-goscope 1991; 101 (S52): 1–41.8) Uneri A. Migraine and benign paroxysmal positional vertigo:an outcome study o 476 patients. Ear Nose Throat J. 2004; 83:814-815.9) Crevits L, Bosman T, Paemeleire K. Migraine related vertigo: The challenge o the basic science. Clinical Neurology and Neu-rosurgery 2005; 108 :111-112.

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