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Comparison of the results of caloric and video head impulse tests in patients
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Comparison of the results of caloric and
video head impulse tests in patients with
Meniere’s disease and vestibular migraine

Mahmut Sinan Yilmaz, Oguz Kadir

Egilmez, Ahmet Kara, Mehmet Guven,
Deniz Demir & Sena Genc Elden

European Archives of Oto-Rhino-

Laryngology
and Head & Neck

ISSN 0937-4477
Volume 278
Number 6

Eur Arch Otorhinolaryngol (2021)

278:1829-1834
DOI 10.1007/s00405-020-06272-5

1 23
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European Archives of Oto-Rhino-Laryngology (2021) 278:1829–1834
https://doi.org/10.1007/s00405-020-06272-5

OTOLOGY

Comparison of the results of caloric and video head impulse tests

in patients with Meniere’s disease and vestibular migraine
Mahmut Sinan Yilmaz1   · Oguz Kadir Egilmez1   · Ahmet Kara1   · Mehmet Guven1   · Deniz Demir1   ·
Sena Genc Elden1 

Received: 27 April 2020 / Accepted: 3 August 2020 / Published online: 9 August 2020
© Springer-Verlag GmbH Germany, part of Springer Nature 2020

Abstract
Purpose  To compare the results of video head impulse test (vHIT) and caloric testing (CT) in patients with vestibular
migraine (VM) and Ménière’s disease (MD) and to investigate the relationship between these two tests.
Methods  Patients with definite unilateral MD and VM were included in the study. All patients underwent both vHIT and
CT. The vestibulo-ocular reflex (VOR) gains of lateral semicircular canals and saccadic waves in vHIT and the canal paresis
factor for the CT were examined.
Results  CT was found abnormal in 39 (66.1%) patients with MD and in 17 (34%) patients with VM, while abnormal gain of
the lateral canal was obtained in 23 MD (39%) patients and 9 (18%) VM patients. In all, 11.9% of patients with an abnormal
vHIT had a normal CT, whereas 33.9% of those with an abnormal CT had a normal vHIT.
Conclusion  Loss of VOR detected by caloric testing is more common and severe in MD than VM. Although vHIT is useful
and can give complementary information, vestibular testing with the caloric test still seems more sensitive for detecting
hVOR pathology.

Keywords  Meniere’s disease · Vestibular migraine · Videonystagmography · Caloric test · Video head impulse test

Introduction Vestibular symptoms are more common in patients

Both Meniere’s disease (MD) and vestibular migraine (VM)
are common causes of vertigo. Although it is thought to be
a central cause of vertigo, VM has some similar character-
istics to MD, which is an inner ear disease with spontaneous
episodic vertigo, fluctuant sensorineural hearing loss, aural
fullness and tinnitus. MD is an idiopathic disease developed
as a result of endolymphatic hydrops [1]. Since a definite
diagnosis of MD can only be determined by histopathologic
study of the temporal bone after death, guidelines are used
for the clinical diagnosis of MD [2].
This study was presented as a poster presentation in the American
Academy of Otolaryngology-Head and Neck Surgery Annual
Meeting and OTO Experience, 15th–18th of September 2019,
New Orleans, USA.
* Oguz Kadir Egilmez
oguzegilmez@gmail.com
1
Department of Otorhinolaryngology, Faculty of Medicine,
Sakarya University Training and Research Hospital,
Sakarya, Turkey
with migraine than in other people. Spontaneous vertigo
with nausea and vomiting, motion intolerance, photopho-
bia, phonophobia and dizziness are the common vestibular
symptoms of migraine-related vertigo. Vestibular migraine
is a disease characterized by episodic vertigo and typical
migraine symptoms and is estimated to occur in 9% of
migraine patients [3]. Cochlear complaints such as hearing
loss, tinnitus and aural fullness may be seen but less so in
patients with VM.
In addition to having similar symptoms, there is a remark-
able overlap between MD and VM [4]. Furthermore, the
incidence of migraine is significantly higher among patients
with MD than other people. Neff et al. [5] reported that 28%
of MD patients had symptoms of VM and 23% patients with
VM had coexistent MD.
There is no specific test that can be used for an exact
diagnosis of VM and MD. They are both clinical condi-
tions that can be diagnosed according to guidelines [1, 6].
No laboratory test can be used to differentiate these two
diseases. To date, some laboratory tests including caloric
test, vestibular evoked myogenic potential (VEMP) testing,

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1830
videonystagmography and MRI have been used for the dif-
ferential diagnosis of MD and VM in a few studies [4, 7,
8]. Video head impulse test (vHIT) is a new testing battery
that can be used for the differential diagnosis of peripheral
vestibular disorders. It evaluates the gain of vestibulo-ocular
reflex (VOR) of each semicircular canal and can give com-
plementary information to caloric testing [9].
The aim of this study was to compare the results of vHIT
and caloric testing in patients with VM and MD and to inves-
tigate the correlation between these two tests in all patients.
We also aimed to specify which test is more sensitive for the
detection of peripheral vestibular disorders.
Materials and methods
Patients with definite unilateral MD who met the criteria
of the American Academy of Otolaryngology-Head and
Neck Surgery 1995 guidelines and patients with definite
VM according to the Neuhauser criteria between January
2016 and February 2020 were included in the study. Patients
whose hearing thresholds were > 20 dB in the frequency
range of 250–500 Hz were excluded from the VM group to
prevent confounding between MD and VM. Patients were
also excluded if there was any history of otologic disease
or surgery, central nervous system disease, intratympanic
gentamicin therapy or systemic disease that could affect the
vestibular system.
A detailed clinical history was obtained from all patients,
who then underwent otorhinolaryngological and neurologi-
cal examination by the same physician. Subsequently, pure
tone audiometry, caloric testing and vHIT were applied to
all patients on the same day.
The authors assert that all procedures contributing to
this work comply with the ethical standards of the relevant
national and institutional guidelines on human experimen-
tation (Institutional Review Board of the Sakarya Univer-
sity Board of Ethics. (No: 11.23.2018/265)) and with the
Helsinki Declaration of 1975, as revised in 2008. Informed
consent was obtained from all patients prior to testings.
Caloric testing
The bithermal caloric test was performed with the Otomet-
rics ICS Chartr 200 VNG and Air Caloric System (GN Oto-
metrics A/S, Denmark) in the supine position with 30° head
flexion and air irrigator airflow of 8 L/min at 50° and 24°
within 60 s. Between irrigations, at least a 5 min interval
was allowed. Horizontal eye movements were recorded with
a binocular video-oculography system. Following each irri-
gation, the maximum slow phase velocity (SPV) of nystag-
mus was calculated. Jongkees formula was used to determine
directional preponderance (DP) and canal paresis (CP). A
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European Archives of Oto-Rhino-Laryngology (2021) 278:1829–1834
response difference > 25% between the two ears was defined
as CP and a result > 30% was defined as DP.
Video head impulse test
EyeSeeCam® vHIT (Interacoustics, Middelfart, Denmark)
was used to record hVOR by one expert technician in our
vestibular laboratory. The system uses lightweight goggles
with an integrated video-oculography camera with a sam-
pling rate at 220 Hz tightly fixed to the head. The patients
were instructed to fix their eyes on a dot on the wall at about
1.2 m distance while the technician manipulated the patient’s
head with quick and unpredictable head movements. The
targeted head velocities during the tests were 200°/s. Eye
and head velocities were captured at 40, 60 and 80 ms after
initiation of the head impulse and averaged. The ratio of
mean eye velocity and mean head velocity expresses the
velocity gain of the hVOR. The test was repeated at least
20 times on each side. A gain value of the horizontal canal
below 0.79 was considered as abnormal. Overt and covert
refixation saccades were also noted.
Statistical analysis
Descriptive analyses were performed to provide information
on general characteristics of the study population. Kolmogo-
rov–Smirnov test was used to evaluate whether the distribu-
tion of numeric variables was normal. Accordingly, it was
seen that some scales displayed a normal distribution. There-
fore, either two independent sample t test or Mann–Whit-
ney U test was used to compare numeric variables between
the two groups. Numeric variables are presented as either
mean ± standard deviation or median [Q1–Q3]. Categorical
variables were compared with a suitable form of the Chi-
square test. Categorical variables are presented as count
and percentage. A p value < 0.05 was considered signifi-
cant. Analyses were performed using SPSS statistical soft-
ware (IBM SPSS Statistics, Version 22.0. Armonk, NY: IBM
Corp.)
Results
We enrolled 59 patients with definite unilateral MD, and
50 patients with VM. Of the 59 patients with MD, 20
were male and 39 were female and the average age was
48.37 ± 11.66  years (between 22–77). The VM group
comprised 7 male and 43 female patients with a mean age
44.86 ± 9.36 years (between 16–63). Male:female ratio was
1:2 in MD and 1:6 in the VM group. According to the Kol-
mogorov–Smirnov test, there was no significant difference
between the groups in terms of age, but there was a signifi-
cant difference for gender. While 21 (35%) patients with MD
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European Archives of Oto-Rhino-Laryngology (2021) 278:1829–1834 1831

Table 1  Demographic findings of the patients Table 3  Results of vHIT in MD and VM patients

MD (n = 59) VM (n = 50) p value MD (n = 59) VM (n = 50) p value

Age 48.37 ± 11.66 44.86 ± 9.36 0.2 vHit

Gender  Abnormal 23 (39%) 9 (18%) 0.017
 Male 20 (33.9%) 7 (14%)  < 0.001  Normal 36 (61%) 41 (82%)
 Female 39 (66.1%) 43 (86%) Saccade
Headache (yes) 21 (35.6%) 50 (100%)  < 0.001  No 37 (62.7%) 45 (90%)  < 0.001
Migraine (yes) 9 (15.3%) 50 (100%)  < 0.001  Overt 18 (30.5%) 4 (8%)
 Covert 4 (6.8%) 1 (2%)
MD Meniere’s disease, VM vestibular migraine, n number
Gain asymmetry (yes) 21 (35.6%) 12 (24%) 0.191

vHIT video head impulse test, MD Meniere’s disease, VM vestibular

Table 2  The caloric test results in MD and VM patients migraine, N normal, AN abnormal, n number
Caloric response MD (n = 59) VM (n = 50) p value

Normal 16 (27.1%) 29 (58%)  < 0.05

CP 39 (66.1%) 17 (34%)
DP 4 (6.8%) 4 (8%)
Table 4  Comparison of the results of vHIT and caloric test in VM
MD Meniere’s disease, VM vestibular migraine, n number, CP canal
and MD patients
paresis, DP directional preponderance
Caloric testing N Caloric testing AN

had a history of headache, 9 (15%) patients had migraine
history (Table 1).
Caloric testing was abnormal in 39 (66.1%) patients with
MD and in 17 (34%) patients with VM. Only DP was found
in four (6.8%, 8%, respectively) patients in both VM and
MD groups, and DP and CP together were found in nine
(15.25%) patients in the MD and three (6%) patients in the
VM group. The difference between the two groups in caloric
testing was statistically significant (p = 0.05) (Table 2).
Abnormal gain of the lateral canal was obtained in 23
(39%) MD patients and 9 (18%) VM patients. The difference
between the two groups in vHIT was statistically significant
(p = 0.017). Refixation saccades and gain asymmetry were
seen in 22 (37.3%) and 21 (35.6%) patients, respectively, in
the MD group and in 5 (10%) and 12 (24%) patients, respec-
tively, in the VM group. Regarding saccades, there was a
statistically significant difference, but according to the gain
asymmetry there was no statistically significant difference
between the two groups (p < 0.001, p = 0.191, respectively)
(Table 3). The gain of the lateral canal was normal in three
of five patients with refixation saccades in the VM group,
whereas it was normal in 6 of 22 patients with refixation
saccades in the MD group. If we compare the anterior and
posterior canal vHIT results in VM and MD patients, the
results of all four canals (right anterior, left posterior, left
anterior, right posterior) were not statistically significant
(p = 0.313, p = 0.955, p = 0.154, and p = 0.079; respectively).
Both caloric testing and vHIT were abnormal in 16 (27.1%)
patients in the MD group and in 3 (6%) patients in the VM
group. An abnormal vHIT was obtained in 16 of 39 patients
with abnormal caloric testing of MD patients, while it was
MD
 vHIT N 13 (22%) 23 (39%)
 vHIT AN 7 (11.9%) 16 (27.1%)
VM
 vHIT N 27 (54%) 14 (28%)
 vHIT AN 6 (12%) 3 (6%)
vHIT video head impulse test, MD Meniere’s disease, VM vestibular
migraine, N normal, AN abnormal, n number
obtained in 3 of 17 patients with abnormal caloric testing of
VM patients. Among the 20 patients with MD whose caloric
testing was normal, vHIT was abnormal in 7 patients. In the
VM group, 6 of 33 patients with normal caloric testing had
abnormal vHIT results (Table 4). Considering the entire group,
abnormal vHIT was obtained in 19 of 56 (33.9%) patients
whose caloric testing was pathological and among the 53
patients with normal caloric responses vHIT was abnormal
in 13 cases (24.5%).
Correlation analysis in all 109 patients using Spearman’s
rank test indicated a significant, but only weak correlation
(r = 0.214, p = 0.026) of CP degree of CT and VOR gains of
lateral canals in vHIT (Fig. 1). In VM patients, correlation
analysis between ipsilateral sum of SPVs and ipsilateral VOR
gains was not statistically significant (r = 0.029, p = 0.774)
(Fig. 2), but in MD patients, correlation between sum of SPVs
and VOR gains of lateral canals of affected ears was statisti-
cally significant (r = 0.189, p = 0.049) (Fig. 3).

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1832 European Archives of Oto-Rhino-Laryngology (2021) 278:1829–1834

Fig. 1  Spearman correlation
analysis (r = 0.214, p = 0.026)
of canal paresis factor and gains
of lateral canals in video head
impulse test for the entire study
population including patients
with Ménière’s disease (blue
squares) and vestibular migraine
(green diamonds). hVOR
vestibulo-ocular reflex gain of
horizontal (lateral) canal

Fig. 3  Analysis of the correlation between sum of slow phase veloci-

Fig. 2  Comparison of ipsilateral sum of SPVs during warm and cold
irrigation in caloric testing and ipsilateral vestibulo-ocular reflex gain
on video head impulse test in vestibular migraine patients (Spearman
correlation analysis; r = 0.029, p = 0.774). SPV slow phase velocity,
hVOR vestibulo-ocular reflex gain of horizontal (lateral) canal
ties in caloric testing and vestibulo-ocular reflex gain on video head
impulse test of an affected ear in Ménière’s disease patients. Scat-
ter plot shows significant positive weak correlation between the two
parameters in the affected ears (r = 0.189, p = 0.049). SPV slow phase
velocity, hVOR vestibulo-ocular reflex gain of horizontal (lateral)
canal

Discussion
Vestibular migraine is a common disease causing recurrent
vertigo attacks and/or disequilibrium in patients with cur-
rent or previous migraine history. It has much similarity
to MD. The most widely accepted diagnosis criteria have
been suggested by Neuhauser et al. for VM and AAOHNS
for MD [1, 6]. Since vertigo attacks are associated with
migraine symptoms in only 65% of patients, VM can
be misdiagnosed. Furthermore, headaches and vertigi-
nous symptoms may appear independently. To diagnose
MD definitively, sensorineural hearing loss is required.
However, cochlear symptoms including subjective hear-
ing loss, aural pressure and tinnitus can occur in 1/3 of
patients with VM [5]. Another challenging feature is that

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European Archives of Oto-Rhino-Laryngology (2021) 278:1829–1834 1833
MD patients may have more headaches than other people.
Neff et al. reported that half of the patients with MD had
headaches with migraine features that did not meet full
IHS diagnostic criteria, migraine symptoms such as photo-
phobia and headache with vomiting [5]. In addition, there
is an overlap between VM and MD. Because there is no
laboratory test that can help in the diagnosis of both MD
and VM, differential diagnosis can be challenging most
of the time. More specific diagnostic tools are needed to
differentiate these two diseases. Zuniga et al. [7] inves-
tigated whether the cVEMP or oVEMP responses could
differentiate VM from MD. They showed that VM and MD
behave similarly with both VEMP tests. Gürkov et al. [4]
investigated the prevalence of endolymphatic hydrops in
patients with definite or probable VM with hearing-related
symptoms using an enhanced inner ear MRI technique.
They concluded that this technique may be useful in the
differential diagnosis of patients with VM and auditory
symptoms since it can detect endolymphatic hydrops in a
proportion of these cases.
Caloric testing is still the most widely used laboratory
test in clinics, since it can identify the presence and side
of peripheral vestibular hypofunction by measuring VOR
response to ear-specific irrigation with warm and cold water
or air. Although caloric testing has been the gold standard
method for demonstrating vestibular hypofunction, it has
some limitations, such as caloric irrigation producing a uni-
lateral low-frequency stimulation and providing only a non-
physiological stimulation of the peripheral vestibular organ.
Furthermore, caloric testing is a time-consuming examina-
tion that can also be unpleasant for patients due to nausea
and dizziness.
The video head impulse test is a new test that is relatively
easy to use, quick and simple for evaluating each semicircu-
lar canal function. It can not only measure the gain of VOR
for each semicircular canal, but also identify overt and covert
refixation saccades. Another advantage of vHIT is that it
does not cause nausea or dizziness.
Both caloric testing and vHIT can measure the unilateral
weakness of horizontal semicircular canal function using
VOR. While the caloric test measures vestibular function at
low frequency, vHIT evaluates VOR in response to high-fre-
quency head movements. When compared to caloric testing,
it has been shown that vHIT has high specificity (90–100%)
but low sensitivity (34–56%) in several studies with differ-
ent vestibular disorders [10–12]. Yoo et al. [13] compared
the abnormal rates of caloric and vHIT in 36 patients with
VM and in 23 patients with vestibular neuritis (VN) in a
recent study. They found pathologic CP in all cases of VN
and in 15 (42%) cases with VM. They also observed abnor-
mal vHIT results in 20 (87%) patients with VN and only in
3 (8%) patients with VM. In this study, when considering
the whole group, abnormal vHIT was obtained in 19 of 56
(33.9%) patients whose caloric testing was pathological and
among the 53 patients with normal caloric responses vHIT
was abnormal in 13 cases (24.5%).
Bell and colleagues [14] investigated the relationship
between vHIT and caloric testing in 51 patients with bal-
ance disorders. Of the 51 patients, 14 had significant canal
paresis. They found no correlation between magnitude of
canal paresis and mean lateral canal VOR gain and con-
cluded that VOR gain could not be used as a predictor of
canal paresis. But in our study, correlation analysis in all
patients using Spearman’s rank test indicated a significant,
but only weak correlation (r = 0.214, p = 0.026). Park et al.
[15] compared the results of vHIT and caloric test in patients
with dizziness and in healthy volunteers and evaluated the
role of vHIT in lateralization vestibulopathy. They found a
statistically significant negative correlation between VOR
gain of the affected ear and unilateral weakness and con-
cluded that a VOR gain of vHIT might be considered as a
valuable objective parameter for evaluating unilateral and
bilateral hypofunction. Mahringer and Rambold [16] showed
that 41% of patients with CP had pathological vHIT and this
percentage increased in cases of acute disease to 63% and
decreased in non-acute disease cases to 33%. They reported
the sensitivity and the specificity of vHIT as 41% and 92%
compared to caloric irrigation.
Although there have been many studies comparing the
results of vHIT and caloric test in different peripheral ves-
tibular diseases, there are only a few studies regarding the
results of vHIT and caloric test in patients with VM and
MD. Blödow and colleagues [8] compared the results of
caloric testing and vHIT in 53 patients with VM and MD
to determine which test was more sensitive for the diag-
nosis of peripheral hypofunction. They found that caloric
testing was abnormal in 67% of patients with MD and 22%
with VM and also found pathological vHIT results in 37%
of MD and 9% of VM patients. They reported that caloric
test was abnormal in 47% of patients compared with 25%
for vHIT. They also found no statistical difference between
caloric test and vHIT results and reported that the sensitiv-
ity of vHIT with caloric test was 52% for the entire group,
55% for MD and 40% for VM patients. Our results are
compatible with the literature results except for caloric
responses of VM. We found a pathological caloric testing
in 34% patients with VM and this was quite a bit higher
than that in previous studies [5, 17, 18]. We think that the
reason of the higher results is that the patients who were
followed with the diagnosis of VM and had pathology in
caloric test may experience hearing loss and develop into
MD in the future or these patients may have vestibular
Meniere. Regarding vHIT results, 39% of patients with
MD and 18% of patients with VM had abnormal vHIT
results. These results are also compatible with those of
previous studies [8, 16]. Our results showed that both
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1834
caloric testing and vHIT were significantly more often
abnormal in patients with MD than in VM patients. The
correlation between the two tests was poor for both MD
and VM.
In our study, male:female ratio was 1:2 in the MD and 1:6
in the VM group. It is known that the majority of patients in
VM and MD are women, and similar results were obtained
in our study. However, there has been no previously men-
tioned information about gender difference affecting caloric
test and vHIT results. Studies using these tests in the litera-
ture were conducted regardless of gender [12, 13].
If the timing of testing was considered, the tests used in
our study were performed when the patients were in healthy
intervals. As these patients already experience nausea,
vomiting and severe vertigo in the acute period, it is diffi-
cult to perform vestibular diagnostic tests, such that caloric
test triggers vestibular symptoms even in a healthy person.
Although the disease is thought to progress after each attack,
it has been reported that the caloric test and vHIT results in
MD and VM patients do not depend on whether the disease
is at an early or advanced stage [12].
As a conclusion; in addition to having similar cochleo-
vestibular symptoms, there is a remarkable overlap between
MD and VM. More diagnostic tests are needed to differen-
tiate between these two diseases. Loss of VOR detected by
caloric testing is more common and severe in MD than VM.
Although vHIT is useful, vestibular testing with the caloric
test still seems more sensitive for detecting hVOR pathol-
ogy. We think that vHIT cannot be used as a substitute for
the caloric test. But it can give complementary information
and both tests can be used in combination.
Author contributions  Conceptualization: MSY, OKE. Data curation:
MSY, OKE, SG. Formal analysis: MG, DD. Methodology: MSY, OKE.
Project administration: MSY, SG. Writing-original draft: MSY, OKE.
Writing-review and editing: AK, MG, DD, SGE.
Funding None.
Compliance with ethical standards  impulse test and air calorics. Eur Arch Otolaryngol 272:1287–1294
Conflict of interest  The authors declare that they have no conflict of
interest.
Ethical approval  All procedures performed in studies involving human
participants were in accordance with the ethical standards of the insti-
tutional and/or national research committee and with the 1964 Helsinki
Declaration and its later amendments or comparable ethical standards.
The study was approved by Institutional Review Board of the Sakarya
University Board of Ethics. (No: 11.23.2018/265).
Consent to participate  Informed consent was obtained from all indi-
vidual participants included in the study.
Consent for publication  Informed consent was obtained from all indi-
vidual participants included in the study.
13
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