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Clinical Characteristics and Treatment Outcome in Patients with Migrainous Vertigo

Jae Hoon Jung, MD; Jae Ryung Lee, MD; Myung Hoon Yoo, MD; Hong Ju Park, MD, PhD; Jong Woo Chung, MD, PhD. Department of Otolaryngology, Asan Medical Center, University of Ulsan College of

Medicine

INTRODUCTION

RESULTS

Table 1. Label in 24pt Arial.

Figure 1. Label in 24pt Arial. Figure 2. Label in 24pt Arial.

ABSTRACT

METHODS AND MATERIALS

DISCUSSION & CONCLUSIONS

REFERENCES CONTACT

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ORGANIZATION’S HIGH RESOLUTION

LOGO

Objective: The aims of the study were to

evaluate abnormal results of vestibular

function tests including caloric, vestibular-

evoked myogenic potentials and dynamic

posturography and to pursue any

association between the response to

medication and abnormal results.

Materials and Methods: One-hundred-

sixteen patients of migrainous vertigo with

recurrent vertigo attacks for more than 6

months were included. Combination of life

style modification and medications were

used for prevention of symptoms. Patients

were asked to rank therapeutic efficacy

utilizing a numeric scale from 0 to 100% of

the improvement of overall severity of

headache and vertigo. Patients were

assigned into three groups; complete

remission, symptomatic improvement ≥

50%, and < 50% after 6-month treatment.

The periods needed for symptomatic

improvement ≥ 50% were recorded and

responsiveness to medications and

vestibular test results metrics were

analyzed to identify clinical predictors for

outcomes.

Results: Symptomatic improvement ≥

50% of vertigo and headache was

observed in 72 % and 78%, respectively.

The mean periods for the symptomatic

improvement were 2.4, and 2.3 months for

vertigo and headache, respectively. The

improvement of vertigo did not coincide

with the improvement of headache in all.

Abnormal rates of caloric, VEMP, and

vestibular ratio were 27%, 30%, and 55%,

respectively. Although abnormal caloric

results showed no significant difference

among 3 groups, abnormal vestibular ratio

on posturography showed significant

correlation with poor response of vertigo

and normal VEMP was significantly

related to the complete remission of

headache. Poor response of vertigo was

observed in 7% of patients with normal

vestibular ratio and 35% of patients with

abnormal vestibular ratio. Complete

remission of headache was observed in

62% of patients with normal VEMP and

30% in patients with abnormal VEMP.

Conclusions: Over 70% of patients with

migrainous vertigo experienced

improvement of both headache and

vertigo by combination of life style

modification and medications. Abnormal

vestibular ratios on posturography and

abnormal VEMP responses were frequent

findings and were indicators of poor

prognosis. Pathophysiology of migrainous

vertigo seems to be closely related to the

vestibular abnormality especially in

vestibule-spinal pathways.

A retrospective chart review from March 2011 to

September 2012 identified 116 patients with a

diagnosis of (MV) with recurrent vertigo attacks

for more than 6 months. A diagnosis of the

migrainous vertigo and migraine were based on

the criteria of Neuhauser et al. and the

International Headache Society (IHS) 2004

criteria, respectively .

Caloric test

Jongkees formula was used to determine canal

paresis, which was considered pathologic when

it was ≥ 20%.

VEMPs

The result was considered pathologic as

followed: IADR > 40% or interaural difference of

thresholds > 15 dB or absence of VEMP.

SOT of dynamic posturography

Each of six different conditions consisted of

three trials, giving a total of 18 trials. After each

test, an equilibrium score ranging between 0%

(fall) and 100% (did not sway at all) resulted.

Somatosensory ratio (ratio of mean values

condition 2/condition 1), visual ratio (ratio of

mean values condition 4/condition 1), and

vestibular ratio (ratio of mean values condition

5/condition 1) beyond the normative data by

manufacturer were considered abnormal.

Treatment protocol and assessments of

outcome

The antimigrainous medications were given by

3-step regimen. On the first visit, flunarizine (5

mg/day) was given as the first-line medication.

The effect of this drug was evaluated on the next

follow-up visit which was usually 2-3 weeks after

the first visit. Patients were followed up on a

monthly basis. Amitriptyline was considered as a

second-line medication if there was no

improvement of symptoms or side effects occur.

It was started at 10 mg/day and the dosage was

increased by 10-20 mg every month up to 90

mg/day till there was some improvement of

symptoms. A third-line drug was topiramate, an

anticonvulsant drug. The drug was started at 25

mg/day and increased by 25 mg every week and

a maximum dosage of 100 mg/day was given for more than 2 months.

Over 70% of patients with migrainous vertigo

experienced improvement of both headache and

vertigo by combination of life style modification

and medications.

Abnormal vestibular ratios on posturography and

abnormal VEMP responses were frequent

findings and were indicators of poor prognosis.

Pathophysiology of migrainous vertigo seems to

be closely related to the vestibular abnormality especially in vestibule-spinal pathways.

Vestibular symptoms including vertigo may occur

relevantly to headaches in many patients with

migraine, however the diagnosis of migrainous

vertigo (MV) is a challenging matter for a

clinician. In spite of increasing number of studies

related to MV, most of previous studies focused

on the characteristics of the disease including

the results of neurotologic tests and its treatment

and prognosis has not been fully documented.

For the sake of counseling therapeutic planning,

it is important to appreciate prognostic factors

before starting treatment and predict the disease

course with treatment. In this study, we tried to

evaluate response to medication in patients with

MV, and determine any association between the

responsiveness and the abnormal vestibular

results of caloric, vestibular-evoked myogenic

potentials (VEMP), and dynamic posturography.

1. Neuhauser H, Leopold M, von Brevern M, et al. The

interrelations of migraine, vertigo, and migrainous vertigo.

Neurology 2001;56:436-41.

2. Vitkovic J, Paine M, Rance G. Neuro-otological findings in

patients with migraine- and nonmigraine-related dizziness.

Audiol Neurootol 2008;13:113-22.

3. Lempert T, Neuhauser H. Epidemiology of vertigo, migraine

and vestibular migraine. J Neurol 2009;256:333-8.

The severity of each symptom was scored as 100%

when it was the same as the severest degree the patient

had experienced before the start of management and

0% when there was no symptom and the symptom

scores were collected at each clinical visit. The period

needed for improvement of subjective symptoms ≥ 50%

were analyzed. Each patient was classified into three

subgroups 6 month after beginning of treatment

according to treatment outcome in vertigo and headache,

respectively: complete remission (CR), symptomatic

improvement ≥ 50% (good response, GR), and < 50% (poor response, PR) groups.

Variable

Total patients (n = 116)

Sex, n (%)

Male 26 (22.4)

Female 90 (77.6)

Mean age, year (range) 46.8 (11-84)

History of vertigo (years), mean (range) 3.9 (0.5-20.0)

Period between onset of headache and vertigo (years), mean (range) 3.4 (0.25)

Mean age, year (range) 46.8 (11-84)

Types of vertigoa, n (%)

Spontaneous 36 (31.0)

Positional 104 (89.7)

Spinning of environment 55 (47.4)

Head motion intolerance 27 (23.3)

Duration of vertigo attacks

< 5min 36 (31.0)

5 to < 60 min 25 (21.6)

1 to < 24 hr 43 (37.1)

≥ 24 hr 12 (10.3)

Cochlear symptoms during vertigo spellsa

Tinnitus 44 (37.9)

Earfullness 32 (27.6)

Hearing loss 26 (22.4)

Time relationship of headache and vertigo

Vertigo prior 81 (69.8)

Head prior 22 (19.0)

Simultaneous 13 (11.2)

Migraine, n (%)

With aura 14 (12.1)

Without aura 102 (87.9)

Headache, n (%)

Hemicranial 99 (85.3)

Holocranial 17 (14.7)

Family history of migraine 28 (24.1)

Migrainous symptoms associated with vertigo attacksa

Headache 107 (92.2)

Phonophobia 103 (88.8)

Photophobia 49 (42.2)

Aura 14 (12.1)

Table 1.Clinical characteristics of patients with migrainous vertigo

Variables n

Anti-migrainous medication

Flunarizine 47(41%)

Flunarizine, Amitriptyline 35 (30%)

Flunarizine, Amitriptyline, Topiramate 34 (29%)

Mean period for improving symptom ≥ 50%, month (range)

Vertigo 2.4 (0.5-12)

Headache 2.3 (0.5-13)

Treatment result (vertigo)

Complete remission 57 (49%)

Good response 26 (22%)

Poor response 33 (28%)

Treatment result (headache)

Complete remission 63 (54%)

Good response 27 (23%)

Poor response 26 (22%)

Table 2. Anti-migrainousmedications and treatment results (n = 116)

Test n (%) Treatment response groups

Pa CR GR PR

Caloric test (n=105)

Normal 77 (73.3) 42 (80.8) 19 (59.4) 16 (76.2) 0.093

Abnormal 28 (26.7) 10 (19.2) 13 (40.6) 5 (23.8)

VEMPs (n=101) Normal 71 (70.3) 40 (80.0) 18 (64.3) 13 (56.5)

0.089 Abnormal 30 (29.7) 10 (20.0) 10 (35.7) 10 (43.5)

SOT (n =

62)

Somato- sensory

Normal 52 (83.9) 22 (84.6) 17 (77.3) 13 (92.9) 0.507

Abnormal 10 (16.1) 4 (15.4) 5 (22.7) 1 (7.1)

Visual Normal 31 (50.0) 14 (53.8) 11 (50.0) 6 (42.9)

0.803 Abnormal 31 (50.0) 12 (46.2) 11 (50.0) 8 (57.1)

Vestibular Normal 28 (45.2) 14 (53.8) 12 (54.5) 2 (14.3)

0.031 Abnormal 34 (54.8) 12 (46.2) 10 (45.5) 12 (85.7)

Vision preference

Normal 48 (77.4) 20 (76.9) 16 (72.7) 12 (85.7) 0.631

Abnormal 14 (19.4) 6 (23.1) 6 (27.3) 2 (14.3)

Table 3.Comparison of caloric test, VEMP, and posturography according to

treatment response group relating vertigo

Test n (%) Treatment response groups

Pa CR GR PR

Caloric test (n=105)

Normal 77 (73.3) 77 (73.3) 46 (79.3) 16 (64.0) 0.291

Abnormal 28 (26.7) 28 (26.7) 12 (20.7) 9 (36.0)

VEMPs (n=101) Normal 71 (70.3) 71 (70.3) 44 (83.0) 13 (52.0)

0.011 Abnormal 30 (29.7) 30 (29.7) 9 (17.0) 12 (48.0)

SOT (n =

62)

Somato- sensory

Normal 52 (83.9) 52 (83.9) 25 (89.3) 15 (78.9) 0.612

Abnormal 10 (16.1) 10 (16.1) 3 (10.7) 4 (21.1)

Visual Normal 31 (50.0) 31 (50.0) 15 (53.6) 8 (42.1)

0.711 Abnormal 31 (50.0) 31 (50.0) 13 (46.4) 11 (57.9)

Vestibular Normal 28 (45.2) 28 (45.2) 14 (50.0) 11 (57.9)

0.069 Abnormal 34 (54.8) 34 (54.8) 14 (50.0) 8 (42.1)

Vision preference

Normal 48 (77.4) 48 (77.4) 22 (78.6) 13 (68.4) 0.424

Abnormal 14 (19.4) 14 (22.6) 6 (21.4) 6 (31.6)

Table 4.Comparison of caloric test, VEMP, and posturography according to

treatment response group relating headache

Figure 1. Abnormal vestibular ratio on sensory organization test in

posturography regarding vertigo.

Figure 2. Abnormal vestibular ratio on sensory organization test in

posturography regarding headache.

DISCUSSION & CONCLUSION