Migraine is THE Most Common Cause of Dizziness

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What seems to be the most under-recognized, yet most common cause of dizziness or vertigo is not an inner ear condition at all – it is migraine. This condition is known as “vestibular migraine” or “migraine-associated dizziness” or “migrainous vertigo”. The main reason it seems to evade diagnosis is that many suffering from this condition are not having headaches at the time they are dizzy. In fact, many patients haven’t had a headache in years or even decades. Patients usually (but not always) have a history of what sounds like migraine headaches, but they will often refer to headaches as “sinus” headaches.

Symptoms of “vestibular migraine” are quite variable, being different from one patient to another and different within the same patient over time. Dizziness and/or vertigo may be reported with a duration of seconds to decades. Patients often have difficulty in describing their symptoms. Morning predominance of dizzy symptoms and visual motion sensitivity are typical. Visual motion sensitivity might include activities such as driving and shopping for items on shelves (especially in big box stores), or being bothered by patterns on clothing or carpeting. Light and/or noise sensitivity are only sometimes present.

Diagnosis of vestibular migraine includes ruling out other causes by vestibular function evaluation (Videonystagmography or VNG, Rotary Chair, Vestibular Evoked Myogenic Potential or VEMP, and an Audiogram). MRI and CT scans or blood tests are rarely necessary.

In the past, many patients suffering from spells of vertigo without hearing loss had been diagnosed with “Vestibular” Meniere’s. However, “Vestibular” Meniere’s is no longer considered a valid diagnosis. The vast majority of these patients were (and likely still are because low salt diet, diuretic, and/or inner ear surgery aren’t helpful treatments for migraine) suffering from “Vestibular” Migraine.

Treatment of vestibular migraine includes recognizing and avoiding trigger factors, and depending on frequency and/or duration of symptoms, preventative migraine medications. In some cases, in particular when motion sensitivity is prominent, a specialized form of physical therapy (PT) known a Vestibular Rehabilitation Therapy (VRT) can be helpful.

Vertigo Sufferers Have Trouble Receiving Correct Diagnosis

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In a 2011 survey by the Vestibular Disorders Association (VEDA), it was determined that those suffering from dizziness (the “dizzy” patient) were on average seen by 4-5 doctors before receiving the correct diagnosis.  As is the case with any medical condition, without the correct diagnosis, the most appropriate treatment cannot be administered.

Symptoms of dizziness are typically subjective and an accurate diagnosis at first may not be straight forward.  Many patients suffering from dizziness typically see several doctors and undergo multiple tests while accumulating large medical bills and no answers.  The time “dizzy” patients spend in this process can be months to years and may result in painful fall-related injuries while seeking help from various healthcare practitioners.

“Dizzy” patients may initially be seen by their primary care physician or go to an urgent care facility or emergency room, then, as the potential underlying cause for dizziness can be diverse, referred to ENT (Ear, Nose and Throat – aka Otolaryngologist), a neurologist and/or cardiologist.  Studies reveal that many undergo brain or sinus CT and/or MRI scans, carotid doppler studies, EEG, EKG, echocardiogram, tilt table testing, and blood tests, all of which have low yield in arriving at the correct diagnosis for most “dizzy” patients.  Vestibular suppressant medications, such as meclizine, diazepam or promethazine, typically offer little relief and the majority of “dizzy” patients do not significantly benefit from PT (physical therapy).

The knowledge and technology we have available today in the diagnosis and treatment of the “dizzy” patient has advanced significantly and is different than what would have been considered standard of care just 20 years ago.  At the initial visit to a physician experienced in vestibular disorders, the “dizzy”patient will be given the most likely diagnosis and a short list of differential diagnoses.  Vestibular function testing and an audiogram (hearing test) are generally the most valuable tests to obtain for the “dizzy” patient, and will help confirm or refute the diagnosis suspected by clinical information obtained in the history and physical exam.

Arriving at the correct diagnosis is vitally important because effective treatment of “dizziness” depends on the diagnosis.  One cause of dizziness requires a specific sequence of head movements which can result in an instant cure, another cause is treated by reducing dietary sodium and/or a diuretic medication, while the most common cause of dizziness improves or resolves with a migraine-preventative medication, and other causes benefit from a specialized form of PT (physical therapy) known as vestibular rehabilitation therapy.

Especially in this age of high deductible health insurance plans, patients are seeking the most expedient and accurate diagnoses and the most effective treatment in a cost-effective manner.  With the advanced diagnostic and treatment capabilities available today, “dizzy” patients should no longer have to see 4-5 doctorsbefore receiving the correct diagnosis.

Vertigo Cure

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There are many causes of dizziness and vertigo that we are now able to recognize and treat. One common type of vertigo, known as BPPV (Benign Paroxysmal Positional Vertigo), aka “the crystal problem”, can be cured with a procedure known as a CRM (Canalith Repositioning Maneuver). Symptoms of BPPVinclude brief vertigo, lasting 10-15 seconds, brought on by lying back or getting up from bed, rolling over in bed, looking up or down. It is important to identify which type of BPPV is present, as we now know multiple types of BPPV exist. With the appropriate CRM, success in treating BPPV is nearly 100%. We should no longer be using medications, such as meclizine, or habituation exercises (Brandt-Daroff or Cawthorne-Cooksey) to treat BPPV. Click here to view a video of the most common type of BPPV, posterior semicircular canal BPPV.

Unfortunately, BPPV has become a well known entity over the years and is now over diagnosed.  Treatment with a CRM in someone who does not have BPPV will not work.  So, if you have been told that you have BPPV, but your vertigo symptoms did not resolve after a correctly performed CRM, then BPPV may not be the correct diagnosis.