See

discussions, stats, and author profiles for this publication at: http://www.researchgate.net/publication/45278283

Editorial: Vertigo and migraine: A more than

two-fold connection
ARTICLE in CEPHALALGIA JULY 2010
Impact Factor: 4.89 DOI: 10.1177/0333102409355603 Source: PubMed

CITATIONS

READS

25

2 AUTHORS:
Andreas Straube

Steven D Rauch

Ludwig-Maximilians-University of Munich

Harvard Medical School

148 PUBLICATIONS 2,006 CITATIONS

97 PUBLICATIONS 1,975 CITATIONS

SEE PROFILE

SEE PROFILE

Available from: Steven D Rauch

Retrieved on: 14 October 2015

Editorial

Vertigo and migraine: A more than

two-fold connection

Cephalalgia
30(7) 774776
! International Headache Society 2010
Reprints and permissions:
sagepub.co.uk/journalsPermissions.nav
DOI: 10.1177/0333102409355603
cep.sagepub.com

Andreas Straube1 and Steven D Rauch2

Migraine headache is one of the most common symptoms in general practice with a 12-month prevalence of
around 1012% in Western populations (1). Vertigo is
no less often the reason for clinical consultations. In
Germany, about 3.4% of all out-patient consultations
are due to the symptom vertigo/dizziness: the 12-month
prevalence for all types of vertigo is about 23% and for
rotational vertigo about 5% (2). Therefore, a concurrence of the two conditions by chance can be expected
in about 1.1%. However, in contrast to this, clinical case
series as well as recent population-based studies showed
a much higher co-occurrence of about 3.2% (37). At
this point, all available evidence points to a related
co-morbidity of migraine and some forms of vertigo.
However, in recent years, it has also become clear that
this association between migraine and vertigo is not due
to a single clinical entity but that several clinical vertigo
syndromes are more often seen in migraine patients (8).
It is still unclear what the underlying pathophysiological mechanism is and whether one mechanism or
several mechanisms are involved. Furthermore, how
can the headache specialist differentiate between
migrainous vertigo and migraine-associated vertigo?
The importance of this point is shown by the study
by Bisdorff and colleagues (9), which shows that dizziness as a symptom during the headache attacks is
reported in 51% of the headache episodes. But this
finding does not differentiate between dizziness due to
the migraine attack per se or due to a co-morbid disorder (e.g. Menie`res disease) which triggers a migraine
attack, as was shown for experimental vestibular stimulation (10). Based on the available data, the life-time
prevalence of migrainous vertigo is about 1%, when the
following criteria were used: (i) recurrent vestibular vertigo (rotational or positional vertigo); (ii) history of
migraine according the International Headache
Society criteria, at least two attacks in which migraine
and vertigo occurred together; and (iii) the vertigo was
not explained by other disorders (6). In some of these
attacks, oculographic recordings were made and pathological nystagmus was seen in 70% of the patients; 50%
showed a more central vestibular dysfunction, 15% eye
movements as in a peripheral vestibular lesion and in

the rest no clear pattern could be detected (11). It is not

clear whether some oculomotor deficits can be seen outside the attacks (4,11). Patients did not complain of
hearing problems during or outside of the attacks.
The onset of the migraine seems to be years earlier
than the onset of the vertigo and the duration of the
vertigo is between 124 h in most attacks (8). The
pathophysiological mechanisms responsible for these
findings are still not known; activation of trigeminal
fibres to the inner ear during the trigeminal-vascular
activation (12), which causes a plasma extravasation,
has been discussed as a possible mechanism. Another
explanation is the induction of a spreading depression
in the brainstem (13) or cortical spreading depression in
vestibular or oculomotor areas (e.g. parietal temporal
cortex). A rare cause of such vertiginous migraine
attacks is episodic ataxia type 2 (14).
Beside the vestibular vertigo during migraine
attacks, other mechanisms may also contribute to the
sensation of dizziness. General increased sensitivity
across all kinds of sensory stimulation (e.g. phonophobia, photophobia, and osmophobia) may be one mechanism. Such a general increased sensitivity may also
contribute to the known increased prevalence of
motion sickness in migraineurs (3,15). Otherwise,
panic attacks are sometimes described by the patients
as dizziness as well and are much more prevalent in
migraineurs than in the general population (16).
Most interesting are the findings that some well
known classic vertigo syndromes, namely Menie`res
disease and benign paroxysmal positional vertigo, can
be found more often than expected in patients with
migraine. In the literature, the prevalence of migraine
in patients with Menie`res disease can be as high as 22
76% (8,17), but population-based studies are still
1

Department of Neurology, University of Munich, Munich, Germany

Department of Otology and Laryngology, Harvard Medical School,
Boston, Massachusetts, USA.
2

Corresponding author:
Prof. Andreas Staube MD, Department of Neurology Ludwig Maximilians
University Munich, Klinikum Grosshadern
Email: astraube@nefo.med.uni-muenchen.de

Downloaded from cep.sagepub.com at University of Sydney on August 16, 2010

775

Editorial
missing. The reason for such a co-morbidity is not
known; a possible mechanism could be the
trigeminal-vascular activation with consecutive plasma
extravasation (18) and, in the long run, development of
an endolymphatic hydrops. Similarly, several case studies indicate an increased risk of benign paroxysmal
positional vertigo (BPPV) in migraine. A study by
Ishiyama et al. (19) found a history of migraine three
times more often in idiopathic BPPV than in traumatic
BPPV (see also Cha and Baloh (8)). In a
population-based study, the prevalence of migraine in
the BPPV group was even 7.5 times higher than in the
controls (20). As in Menie`res disease, the exact connection between migraine and BPPV is not known; one
hypothesis is that the repeated trigeminal vascular activation of the inner ear may also cause an accelerated
degeneration of the membranes of the otoliths which
may be the reason for the shearing-off of otoconia which
then are allocated in the labyrinth. The differentiation
between these syndromes, which are more often present
in migraineurs, and migrainous vertigo in the more
narrow sense is important because the therapeutical consequences are different. In the case of migrainous vertigo, the treatment is related to the migraine, although
controlled studies have not been published yet. In the
case of BPPV, deliberation manoeuvres which help to
reposition the otoconia are the treatment of choice (21).
Menie`res disease can be treated with betahistine or gentamycin installation in the inner ear (22).
The consequence of this is that headache specialists
should be able to differentiate vestibular vertigo (e.g.
rotational or positional vertigo) from a more unspecific
dizziness and they should also be familiar with the most
prevalent oculomotor findings in the case of Menie`res
disease (peripheral spontaneous nystagmus or
head-shaking nystagmus) and BPPV (brief attacks of
a crescendo-decrescendo torsional geotropic-beating
nystagmus in the head hanging position) in order to
differentiate correctly between these disorders. The
challenge for science in the coming years will be to
gain more insight into the pathophysiology of migrainous vertigo.
Historically, migraine has been considered a headache disorder, with a variety of adjunctive symptoms,
including ocular manifestations, allodynia, photophobia and phonophobia, and vertigo/imbalance, to name
a few. This historical fact is reflected in the diagnostic
classifications of the International Headache Society.
What is becoming clearer year by year is that migraine
is a disorder of neurological function that can produce
wide spectrum of changes in sensory perception, usually
an intensification and/or distortion. The conventional,
headache-centric definition of migraine tends to reduce
awareness and importance of the other symptoms and
manifestations of the problem. In the best studies

to-date of the epidemiology of migrainous vertigo, all

patients had to meet International Headache Society
criteria for migraine headache and have vestibular
symptoms (68). However, this may well underestimate
the prevalence of migrainous dizziness. Clinicians specialising in balance disorders will agree that there
are many patients exhibiting all the symptoms and
signs of migrainous dizziness, but no temporally related
headache (or no headache history at all). This is
exactly analogous to ocular migraine, but the ocular
symptoms alone can justify a diagnosis of migraine
even in the absence of headache. It is time to consider
redefining migraine as a global disturbance of sensory
signal processing, in which headache is a common
manifestation.
References
1. Jensen R, Stovner LJ. Epidemiology and comorbidity of
headache. Lancet Neurol 2008; 7: 354361.
2. Neuhauser HK. [Epidemiology of dizziness and vertigo].
Nervenarzt 2009; 80: 887894.
3. Kayan A, Hood JD. Neuro-otological manifestations of
migraine. Brain 1984; 107: 11231142.
4. Dieterich M, Brandt T. Episodic vertigo related to
migraine (90 cases): vestibular migraine? J Neurol 1999;
246: 883892.
5. Cha YH, Lee H, Santell LS, Baloh RW. Association of
benign recurrent vertigo and migraine in 208 patients.
Cephalalgia 2009; 29: 550555.
6. Neuhauser HK, Radtke A, von Brevern M, et al. Migrainous vertigo: prevalence and impact on quality of life.
Neurology 2006; 67: 10281033.
7. Lempert T, Neuhauser H. Epidemiology of vertigo, migraine
and vestibular migraine. J Neurol 2009; 256: 333338.
8. Cha YH, Baloh RW. Migraine associated vertigo. J Clin
Neurol 2007; 3: 121126.
9. Bisdorff A, Andree C, Vaillant M, Sandor PS.
Headache-associated dizziness in a headache population:
prevalence and impact. Cephalalgia Published Online
First 12 March 2010, doi: 10.1177/0333102409353617.
10. Murdin L, Davies RA, Bronstein AM. Vertigo as a
migraine trigger. Neurology 2009; 73: 638642.
11. von Brevern M, Zeise D, Neuhauser H, Clarke AH,
Lempert T. Acute migrainous vertigo: clinical and oculographic findings. Brain 2005; 128: 365374.
12. Koo JW, Balaban CD. Serotonin-induced plasma extravasation in the murine inner ear: possible mechanism of
migraine-associated inner ear dysfunction. Cephalalgia
2006; 26: 13101319.
13. Richter F, Bauer R, Lehmenkuhler A, Schaible HG.
Spreading depression in the brainstem of the adult rat:
electrophysiological parameters and influences on regional brainstem blood flow. J Cereb Blood Flow Metab
2008; 28: 984994.
14. Robbins MS, Lipton RB, Laureta EC, Grosberg BM.
CACNA1A nonsense mutation is associated with
basilar-type migraine and episodic ataxia type 2.
Headache 2009; 49: 10421046.

Downloaded from cep.sagepub.com at University of Sydney on August 16, 2010

776

Cephalalgia 30(7)

15. Drummond PD. Triggers of motion sickness in migraine

sufferers. Headache 2005; 45: 653656.
16. Hamelsky SW, Lipton RB. Psychiatric comorbidity of
migraine. Headache 2006; 46: 13271333.
17. Radtke A, Lempert T, Gresty MA, Brookes GB,
Bronstein AM, Neuhauser H. Migraine and Menie`res
disease: is there a link? Neurology 2002; 59: 17001704.
18. Vass Z, Steyger PS, Hordichok AJ, Trune DR, Jancso G,
Nuttall AL. Capsaicin stimulation of the cochlea and
electric stimulation of the trigeminal ganglion mediate
vascular permeability in cochlear and vertebro-basilar
arteries: a potential cause of inner ear dysfunction in
headache. Neuroscience 2001; 103: 189201.

19. Ishiyama A, Jacobson KM, Baloh RW. Migraine and

benign positional vertigo. Ann Otol Rhinol Laryngol
2000; 109: 377380.
20. Von Brevern M, Radtke A, Lezius F, et al. Epidemiology of
benign paroxysmal positional vertigo: a population based
study. J Neurol Neurosurg Psychiatry 2007; 78: 710715.
21. Bhattacharyya N, Baugh RF, Orvidas L, et al. American
Academy of Otolaryngology-Head and Neck Surgery
Foundation. Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol Head Neck Surg 2008;
139(Suppl 4): S47S81.
22. Straube A. Nystagmus: an update on treatment in adults.
Expert Opin Pharmacother 2005; 6: 583590.

Downloaded from cep.sagepub.com at University of Sydney on August 16, 2010