May 06, 2020
The First Attack of Vertigo – Is it a Stroke or is it Inner Ear Disease?
Vestibular Migraine (VM)
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
Only in about 1/5th of patients first experience is there visual abnormalities e.g. visual complaints such as zig zagging lines or flashing lights, or numbness and tingling of parts of the body or difficulty speaking which last 5-60 min and then resolves
The type of dizziness in an attack is very varied, from vertigo to unsteady on walking to a constant swaying sensation.
The dizziness can last from a few seconds to days but is typically between 5 minutes and 3 days.
Visual experiences such as being on bridges, driving a car, empty rooms, long corridors, large crowds of people in a store or restaurant cinema, television & computers, flashing lights) are worse during an attack but are avoided even when an attack is not happening.
During an attack most patients experience nausea, and over half experience unpleasant sensitivity to sound and light and/or one-sided pulsing headaches with a desire to lie down in a darkened room.
In about a 1/3rd of patients ringing (“tinnitus” ) in their ears is experienced.
Attacks may be triggered by the head being in a certain positions or rapid turning of the head, foods e.g. dark chocolate, periods, stress, lack of sleep, GTN, histamine, ranitidine, HRT, caffeine, exercise, computers, movies and flashing lights.
Between attacks patients describe motion sickness and dislike of strong or flashing light or loud sounds.
Often the patient has a history of migraine headaches “Migraine Cephalgia” (or family history of migraine), motion intolerance and a childhood history of not being able to read in the back of a car.
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.
There are no abnormal findings except during an attack.
Treatment in Adults
Headache dominated migraine with only minor dizziness should be treated by a neurologist with an interest in migraine.
Vertigo dominated migraine with minor headaches should be treated by an ENT doctor..
The Treatment of the Headache – Migraine Cephalgia:
Sleep in a darkened room.
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 4 to 6 hours but shouldn’t take more than 4g (8 500mg tablets) in the space of 24 hours.
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
Rizatriptan benzoate 10mg (Maxalt Malt) asap on onset then 10mg at 2 hours ( if there is no response increase to a maximum dose of 20mg per day.
A combination of a Triptan + Paracetamol Or Triptan + Ibuprofen
The Treatment of Vestibular Migraine:
The acute vertigo and nausea of VM is difficult to treat but usually treated with standard acute migraine régime.
Patients that have vertigo dominated migraine attacks that are causing frequent disability (for example, two or more attacks per month that last for 3 days or more)
Diet & Supplements
All patients should be offered an anti-VM Diet, Vitamin B-2/Riboflavin (400mg o.d) supplements for 3 months minimum, Magnesium Citrate 100mg 100 Caplets taken three caplets daily, preferably with meals ( Do not exceed stated dose and caution with patients with cardiac conduction problems, https://www.hollandandbarrett.com/shop/product/holland-barrett-magnesium-citrate-caplets-100mg-60006390) for 3-4 months and a good sleep pattern
Initially Verapamil SR120mg o.d (depending on the weight) for 4 to 6 weeks and then review if it is working but not sufficiently then increase it up to 180 mg. Contra-indications are patients on B blockers or heart failure. Angina is not a contra-indication.
If no success: –
Nortriptyline 25mg o.d increasing to 50mg (75 mg for males) by 3 weeks. The main side effect is a dry mouth.
With anxiety/depression Venlafaxine selective serotonin and norepinephrine reuptake inhibitors (SSNRIs).
Initial dose: 37.5 mg orally once a day
Taken up to 150mg o.d. (75mg, 112.5mg, 150mg) over 4-6 weeks for 6 months then slide down. There is a tendency to suffer from jitters for the first week.
If theses do not work, then topiramate may be considered, but treatment is more complex due to potential side effects.
In particular women and girls 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.
There may be a role for vestibular therapy and CBD.