One simple question detects motion sickness susceptibility in migraine patients.

OBJECTIVE: To find out if motion sickness susceptibility (MSS) of vestibular migraine (VM) patients and migraine only (MO) patients can be reliably detected with a single simple question: "Can you read while travelling in a car without getting motion sick?". METHOD: Ninety-two definite VM and 58 MO patients and 74 healthy control (HC) subjects were asked about their MSS and about being able to read while riding in a car without becoming motion sick. A Motion Sickness Susceptibility Questionnaire (MSSQ-Short) including childhood (MSA), adulthood (MSB) and total (MST) parts was also administered to all participants. ROC curves of MSSQ-Short were prepared for "not being able to read in a car" as the gold standard. RESULTS: Mean MSA scores were significantly higher in both VM and MO patients than in HCs (p < 0.001), but their scores were not significantly different (p = 0.171). Mean MSB and MST scores were significantly higher in VM than in MO patients (p < 0.001) and both VM and MO patients had significantly higher scores than HCs (p < 0.001). MSA scores were significantly higher than MSB scores in MO patients (p < 0.001). All sections of the questionnaire were associated with high area-under-curve values for MSS detected by the question about being able to read in a car without becoming motion sick. CONCLUSION: We propose that all migraine patients could have the same level of MSS in childhood but MO patients are able to compensate over years, but VM patients are not. A quick way to determine MSS is to ask about the ability to read without becoming motion sickness while riding a car.

One simple question detects motion sickness susceptibility in migraine patients

Abstract Objective To find out if motion sickness susceptibility (MSS) of vestibular migraine (VM) patients and migraine only (MO) patients can be reliably detected with a single simple question: "Can you read while travelling in a car without getting motion sick?". Method Ninety-two definite VM and 58 MO patients and 74 healthy control (HC) subjects were asked about their MSS and about being able to read while riding in a car without becoming motion sick. A Motion Sickness Susceptibility Questionnaire (MSSQ-Short) including childhood (MSA), adulthood (MSB) and total (MST) parts was also administered to all participants. ROC curves of MSSQ-Short were prepared for "not being able to read in a car" as the gold standard. Results Mean MSA scores were significantly higher in both VM and MO patients than in HCs (p< 0.001), but their scores were not significantly different (p= 0.171). Mean MSB and MST scores were significantly higher in VM than in MO patients (p< 0.001) and both VM and MO patients had significantly higher scores than HCs (p< 0.001). MSA scores were significantly higher than MSB scores in MO patients (p< 0.001). All sections of the questionnaire were associated with high area-under-curve values for MSS detected by the question about being able to read in a car without becoming motion sick. Conclusion We propose that all migraine patients could have the same level of MSS in childhood but MO patients are able to compensate over years, but VM patients are not. A quick way to determine MSS is to ask about the ability to read without becoming motion sickness while riding a car.

Vestibular and Oculomotor Findings in Vestibular Migraine Patients.

BACKGROUND: Vestibular migraine (VM) is the most frequent etiology of recurrent spontaneous episodic vertigo. Vestibular and oculomotor abnormalities have been described in VM; however, the diagnosis is currently based on symptoms. The objective of this study was to determine the most frequent abnormalities in videonystagmography (VNG), caloric testing (Cal) and video head impulse test (vHIT) in patients with VM. METHODS: A retrospective cohort study was conducted, including all VM and probable VM patients seen from January 2021 to July 2022. Demographics, auditory symptoms and results via VNG, Cal and vHIT were evaluated. VNG results were compared with a control group. RESULTS: Sixty patients, 81.7% with VM and 18.3% with probable vestibular migraine, were included. VNG revealed the following abnormalities: 21.7% spontaneous nystagmus; 33.3% positional nystagmus, mostly central; 26.7% optokinetic nystagmus; 56.7% smooth pursuit abnormalities and 70% saccade test abnormalities, mostly velocity and latency. An abnormal unilateral caloric response was seen in 22.9%, while vHIT revealed a low gain in at least one canal in 21.7%, and saccades were seen in at least one canal with normal gains in 18.3%. Concordant results between Cal and lateral vHIT were seen in 77.1% of cases. CONCLUSIONS: Although VM is a clinical diagnosis, vestibular and oculomotor abnormalities are commonly seen. The most frequent oculomotor findings were an abnormal saccade test, abnormal smooth pursuit and central positional nystagmus.

Comparison of clinical characteristics and vestibular function test results in patients with vestibular migraine and Menière's disease.

OBJECTIVES: The differentiation between Vestibular Migraine (VM) and Meniere's Disease (MD) is difficult because of overlapping symptoms. The study aimed to compare the clinical characteristics and vestibular function test results between VM and MD patients. METHODS: Seventy-one patients with definite VM and 31 patients with definite unilateral MD were included. All patients received Caloric Test (CT), Video Head Impulse Test (vHIT) and Vestibular Evoked Myogenic Potential (VEMP) test within 7 days after visiting the hospital. Results of these tests were compared between groups. RESULTS: Most VM patients (64.0%) experienced spontaneous internal vertigo, while most MD patients (66.7%) experienced spontaneous external vertigo. MD patients had more severe vestibular symptoms and autonomic responses compared to VM patients during attacks (p =  0.03, p = 0.00, respectively). The nystagmus intensity of CT-induced was greater in VM patients than in MD patients (p = 0.003). More VM patients had CT intolerance and Central Positional Nystagmus (CPN) compared to MD patients (p = 0.002, p = 0.006, respectively). More MD patients had CT(+) and vHIT saccades wave compared to VM patients (p < 0.001, p = 0.002, respectively). The non-elicitation rate of cervical VEMP was higher, and the ocular VEMP amplitudes were lower in MD patients than in VM patients (p = 0.002, p = 0.018). CONCLUSIONS: Vestibular symptoms during attacks combined with the results of vestibular function tests may be used to differentiate between VM and MD. The diverse nature of vestibular symptoms (especially internal vertigo), history of motion sickness and CT intolerance may provide clues to the diagnosis of VM, whereas spontaneous external vertigo, CT(+) with vHIT(-), and the presence of saccades may provide clues to the diagnosis of MD.

Mal de Débarquement Syndrome in Children: A Case Series.

Currently, mal de débarquement syndrome (MdDS) has been reported only among adults. This case series describes 3 pediatric patients with MdDS. MdDS presentation in children is similar to that of adults, although the frequency of comorbid conditions is greater. Diagnostic delays are common and likely due to under-recognition of MdDS among children.

Hallazgos vestibulares y oculomotores en migraña vestibular: una revisión actualizada / Vestibular and Oculomotor findings in vestibular migraine: an updated review

La migraña vestibular es una de las etiologías más frecuentes del síndrome vestibular episódico a nivel mundial. Presenta varias hipótesis de patofisiología, principalmente a nivel de sistema vestibular central y genético. Su diagnóstico es fundamentalmente clínico, pero se han observado alteraciones a nivel de la función vestibular y de las pruebas oculomotoras. Los hallazgos clínicos no solo están presentes en el momento de la crisis, sino también se han observado en intervalos asintomáticos. La paresia unilateral en la prueba calórica suele ser más frecuente que una ganancia baja del reflejo vestíbulo-ocular del canal lateral en la videonistagmografía, sin embargo, existe una tasa elevada de discordancia entre ambas pruebas. Respecto a la prueba de estudio del movimiento ocular, se han observado alteraciones en el seguimiento pendular, movimiento sacádico, nistagmo optocinético, nistagmo evocado por la mirada, nistagmo espontáneo y nistagmo posicional. Es frecuente observar que el nistagmo provocado por cambios posicionales presenta características centrales durante la crisis de migraña vestibular, pero también se pueden presentar en periodos libres de síntomas en este grupo de pacientes.

Vestibular migraine is one of the most frequent etiologies of episodic vestibular syndrome worldwide. It presents several pathophysiology hypotheses, mainly at the central vestibular system and genetic level. Its diagnosis is fundamentally clinical, but changes in vestibular function and oculomotor tests have been observed. Clinical findings are present not only during the crisis, but also have been seen in the symptom-free interval. Unilateral paresis on caloric testing is usually more common than low gain of the vestibulo-ocular reflex in the lateral canal on videonystagmography, however, there is a high rate of discrepancy between these tests. Regarding the eye movement study test, alterations have been seen in pendulum tracking, saccadic movement, optokinetic nystagmus, gaze-evoked nystagmus, spontaneous nystagmus and positional nystagmus. It is common to observe that nystagmus caused by positional changes has central features during vestibular migraine attacks, but it can also be seen in the symptom-free interval in this group of patients.

Comparison of clinical characteristics and vestibular function test results in patients with vestibular migraine and Menière's disease

Abstract Objectives The differentiation between Vestibular Migraine (VM) and Meniere's Disease (MD) is difficult because of overlapping symptoms. The study aimed to compare the clinical characteristics and vestibular function test results between VM and MD patients. Methods Seventy-one patients with definite VM and 31 patients with definite unilateral MD were included. All patients received Caloric Test (CT), Video Head Impulse Test (vHIT) and Vestibular Evoked Myogenic Potential (VEMP) test within 7 days after visiting the hospital. Results of these tests were compared between groups. Results Most VM patients (64.0%) experienced spontaneous internal vertigo, while most MD patients (66.7%) experienced spontaneous external vertigo. MD patients had more severe vestibular symptoms and autonomic responses compared to VM patients during attacks (p= 0.03, p= 0.00, respectively). The nystagmus intensity of CT-induced was greater in VM patients than in MD patients (p= 0.003). More VM patients had CT intolerance and Central Positional Nystagmus (CPN) compared to MD patients (p= 0.002, p = 0.006, respectively). More MD patients had CT(+) and vHIT saccades wave compared to VM patients (p< 0.001, p= 0.002, respectively). The non-elicitation rate of cervical VEMP was higher, and the ocular VEMP amplitudes were lower in MD patients than in VM patients (p = 0.002, p= 0.018). Conclusions Vestibular symptoms during attacks combined with the results of vestibular function tests may be used to differentiate between VM and MD. The diverse nature of vestibular symptoms (especially internal vertigo), history of motion sickness and CT intolerance may provide clues to the diagnosis of VM, whereas spontaneous external vertigo, CT(+) with vHIT(-), and the presence of saccades may provide clues to the diagnosis of MD. Level of evidence: 4.

Clinical characteristics of definite vestibular migraine diagnosed according to criteria jointly formulated by the Bárány Society and the International Headache Society

Abstract Objective: To investigate the clinical features of patients with definite vestibular migraine (dVM). Methods: A total of 91 patients with vestibular symptoms accompanied by migraines/migrainelike symptoms were enrolled and diagnosed according to the criteria of the Bárány Society and the International Headache Society. Baseline data were collected. Videonystagmography and immune-related laboratory tests were performed. Results: Among the 91 patients, 62 (68.1%) had dVM (11 men, 51 women). Among dVM patients, migraine occurred earlier than vestibular symptoms in 42 (67.7%) patients. Spontaneous vertigo occurred in 41 (66.1%) patients. Induced vertigo occurred in 21 (33.9%) patients. Motion sickness occurred in 33 (53.2%) patients. Central oculomotor dysfunction was observed in 11 (17.7%) patients. Caloric test revealed unilateral horizontal semicircular canal dysfunction in 12 (19.4%) patients. Severe intolerance during the test occurred in 44 (71.0%) patients with dVM. 12 (19.4%) patients showed abnormal immune-related indicators. Conclusion: dVM is more common in women. The onset of migraine precedes that of vestibular symptoms, which are often accompanied by photophobia and phonophobia. Motion sickness and severe caloric test intolerance can contribute to the diagnosis of dVM. Immunological indicators are abnormal in some patients with dVM, dVM may be secondary or an accompanying disorder, but the causal relationship needs further investigation. Level of evidence: IV.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine

Abstract Objective: Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine. Methods: Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Preand post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively. Results: With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups. Conclusion: With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit. Level of evidence: Level III (evidence obtained from well-designed controlled trials without randomization).

The effectiveness of propranolol, flunarizine, amitriptyline and botulinum toxin in vestibular migraine complaints and prophylaxis: a non-randomized controlled study / A eficácia de propranolol, flunarizina, amitriptilina e toxina botulínica nas queixas e profilaxia da migrânea vestibular: um estudo controlado não randomizado

Abstract Introduction: Vestibular migraine is the most common cause of spontaneous episodic vertigo in adult patients and the second most common cause of vertigo in patients of all ages. Objective: To assess the effectiveness of oral medication type (propranolol, flunarizine, and amitriptyline) and botulinum toxin A application on vestibular symptoms, headache severity and attack frequency for vestibular migraine patients. Methods: Sixty patients with vestibular migraine were enrolled. Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B− group). Headache severity was evaluated with Migraine Disability Assessment Scale and vertigo severity was evaluated with Dizziness Handicap Inventory scale. Vestibular migraine attack frequencies in the last three months were also evaluated. Results: There was a statistically significant decrement in mean Dizziness Handicap Inventory scores, Migraine Disability Assessment Scale scores and vertigo attack frequencies after treatment for all patients, B+ and B− group patients (p < 0.001 for all). The mean Migraine Disability Assessment Scale score gains (p < 0.001) and vertigo attack frequency gains (p = 0.003) were significantly higher in the B+ patients than B− patients. Conclusions: Both B+ and B− group patients exhibited significant improvement in vestibular migraine attack frequencies, Dizziness Handicap Inventory score and Migraine Disability Assessment Scale score values. However, botulinum toxin A application had a more pronounced effect for Migraine Disability Assessment Scale score gain and vestibular migraine attack frequency values, but not for Dizziness Handicap Inventory score gain values. Thus, botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. The oral medication type (propranolol, flunarizine or amitriptyline) did not differ in influencing the vestibular migraine attack frequency, Dizziness Handicap Inventory score gain and Migraine Disability Assessment Scale score gain values.

Resumo Introdução: A migrânea vestibular é a causa mais comum de vertigem episódica espontânea em pacientes adultos e a segunda causa mais comum de vertigem em pacientes de todas as idades. Objetivo: Avaliar a eficácia da aplicação dos tipos de medicamentos orais (propranolol, flunarizina e amitriptilina) e da toxina botulínica tipo A sobre os sintomas vestibulares, intensidade da cefaleia e frequência das crises em pacientes com migrânea vestibular. Método: Sessenta pacientes com migrânea vestibular foram incluídos. Trinta pacientes receberam tratamento com toxina botulínica tipo A e medicação oral (Grupo B+), enquanto 30 pacientes receberam apenas medicação oral (Grupo B-). A intensidade da cefaleia foi avaliada pelo migraine disability assessment scale e a gravidade da vertigem foi avaliada com o dizziness handicap inventory. A frequência das crises de migrânea vestibular nos últimos três meses também foi avaliada. Resultados: Houve um decréscimo estatisticamente significativo na média dos escores do dizziness handicap inventory e migraine disability assesment scale e na frequência das crises de vertigem após o tratamento em todos os pacientes, p < 0,001 para todos os pacientes dos grupos B+ e B−. Os ganhos médios no escore do migraine disability assesment scale (p < 0,001) e na frequência das crises de vertigem (p = 0,003) foram significantemente maiores nos pacientes B+ do que nos pacientes B−. Conclusões: Os pacientes de ambos os grupos B+ e B− exibiram melhoria significativa na frequência das crises de migrânea vestibular e nos valores dos escores do dizziness handicap inventory e do migraine disability assesment scale. No entanto, a aplicação da toxina botulínica tipo A teve um efeito mais pronunciado para os valores de ganho no escore do migraine disability assesment scale e na frequência das crises de migrânea vestibular, mas não para os valores de ganho no escore do dizziness handicap inventory. Portanto, a aplicação de toxina botulínica tipo A deve ser considerada para pacientes com migrânea vestibular, cujos graus de intensidade da cefaleia são mais marcantes. O tipo de medicação oral (propranolol, flunarizina ou amitriptilina) não diferiu em relação à frequência das crises de migrânea vestibular e aos valores de ganho dos escores do dizziness handicap inventory e do migraine disability assesment scale.

Dissociation between Caloric and Video Head Impulse Tests in Dizziness Clinics.

Vestibular assessment tests such as the video head impulse test (vHIT) for the horizontal semicircular canal, and caloric test (Cal), both evaluate horizontal canal function. One would assume that the outcomes for these tests should lead to concordant results, yet several studies have suggested that dissociation can occur in certain pathological conditions. As this topic remains inconclusive, this review aims to analyze the scientific evidence regarding the patterns of hypofunction observed in vHIT and Cal in different otoneurological diseases. A comprehensive review of the literature regarding dissociation between these tests in common neurotological diseases was carried out. Articles were analyzed when data for vHIT and Cal were described in a way that it was possible to calculate discordance rates; both retrospective and prospective studies were analyzed. In this review, the discordance rates were as follows: 56% in Ménière's disease, 51.5% in vestibular migraine, 37.2% in vestibular schwannoma, and 20.8% in vestibular neuritis. These results highlight the benefit of using both Cal and vHIT, and that they are complementary tests.

Migraine and balance impairment: Influence of subdiagnosis, otoneurological function, falls, and psychosocial factors.

OBJECTIVE: To assess the balance sensory organization among patients with migraine, considering the influence of migraine subdiagnosis, otoneurological function, falls, and psychosocial factors. BACKGROUND: Migraine has been associated with vestibular symptoms and balance dysfunction; however, neither comprehensive balance assessment nor associated factors for greater impairment have been addressed thus far. METHODS: Patients from a tertiary headache clinic with a diagnosis of episodic migraine with aura (MWA), without aura (MWoA), and chronic migraine (CM) were included for this cross-sectional study (30 patients per group). Thirty headache-free controls (CG) were recruited. Participants underwent a comprehensive evaluation protocol, including the Sensory Organization Test (SOT) and otoneurological examination. Questionnaires about fear of falls, dizziness disability, and kinesiophobia were administered. RESULTS: All migraine groups presented lower composite SOT scores than controls (CG: 82.4 [95% confidence interval (CI): 79.5-85.3], MWoA: 76.5 [95% CI: 73.6-79.3], MWA: 66.5 [95% CI: 63.6-69.3], CM: 69.1 [95% CI: 66.3-72.0]; p < 0.0001). Compared to controls and to MWoA, MWA and CM groups exhibited greater vestibular (CG: 75.9 [95% CI: 71.3-80.4], MWoA: 67.3 [95% CI: 62.7-71.8], MWA: 55.7 [95% CI: 51.2-60.3], CM: 58.4 [95% CI: 53.8-63.0]; p < 0.0001) and visual functional impairment (CG: 89.6 [95% CI: 84.2-94.9], MWoA: 83.2 [95% CI: 77.9-88.6], MWA: 68.6 [95% CI: 63.3-74.0], CM: 71.9 [95% CI: 66.5-77.2], p < 0.0001). Fall events during the assessment were documented more often among patients with migraine (CG: 0.0, interquartile range [IQR], 0.0, 0.0); MWoA: 1.0 [IQR: 1.0, 1.0], MWA: 2.0 [IQR: 1.8, 4.3], CM: 1.0 [IQR: 1.0, 2.0]; p = 0.001). The SOT scores correlated with fear of falls (r = -0.44), dizziness disability (r = -0.37), kinesiophobia (r = -0.38), and migraine frequency (r = -0.38). There was no significant influence of the vestibular migraine diagnosis in the study outcomes when used as a covariate in the analysis (composite score [F = 3.33, p = 0.070], visual score [F = 2.11, p = 0.149], vestibular score [F = 1.88, p = 0.172], somatosensory score [F = 0.00, p = 0.993]). CONCLUSIONS: Aura and greater migraine frequency were related to falls and balance impairment with sensory input manipulation, although no otoneurological alterations were detected. The diagnosis of vestibular migraine does not influence the balance performance. The vestibular/visual systems should be considered in the clinical examination and treatment of patients with migraine.

Atypical Positional Vertigo: Definition, Causes, and Mechanisms.

Paroxysmal positional vertigo is a frequent cause for consultation. When approaching these patients, we try to differentiate central from peripheral causes, but sometimes we find manifestations that generate diagnostic doubts. In this review, we address atypical paroxysmal positional vertigo, reviewing the literature on the subject and giving a provisional definition of atypical positional vertigo as well as outlining its causes and pathophysiological mechanisms.

Clinical characteristics of definite vestibular migraine diagnosed according to criteria jointly formulated by the Bárány Society and the International Headache Society.

OBJECTIVE: To investigate the clinical features of patients with definite vestibular migraine (dVM). METHODS: A total of 91 patients with vestibular symptoms accompanied by migraines/migraine-like symptoms were enrolled and diagnosed according to the criteria of the Bárány Society and the International Headache Society. Baseline data were collected. Videonystagmography and immune-related laboratory tests were performed. RESULTS: Among the 91 patients, 62 (68.1%) had dVM (11 men, 51 women). Among dVM patients, migraine occurred earlier than vestibular symptoms in 42 (67.7%) patients. Spontaneous vertigo occurred in 41 (66.1%) patients. Induced vertigo occurred in 21 (33.9%) patients. Motion sickness occurred in 33 (53.2%) patients. Central oculomotor dysfunction was observed in 11 (17.7%) patients. Caloric test revealed unilateral horizontal semicircular canal dysfunction in 12 (19.4%) patients. Severe intolerance during the test occurred in 44 (71.0%) patients with dVM. 12 (19.4%) patients showed abnormal immune-related indicators. CONCLUSION: dVM is more common in women. The onset of migraine precedes that of vestibular symptoms, which are often accompanied by photophobia and phonophobia. Motion sickness and severe caloric test intolerance can contribute to the diagnosis of dVM. Immunological indicators are abnormal in some patients with dVM, dVM may be secondary or an accompanying disorder, but the causal relationship needs further investigation. LEVEL OF EVIDENCE: IV.

The effectiveness of propranolol, flunarizine, amitriptyline and botulinum toxin in vestibular migraine complaints and prophylaxis: a non-randomized controlled study.

INTRODUCTION: Vestibular migraine is the most common cause of spontaneous episodic vertigo in adult patients and the second most common cause of vertigo in patients of all ages. OBJECTIVE: To assess the effectiveness of oral medication type (propranolol, flunarizine, and amitriptyline) and botulinum toxin A application on vestibular symptoms, headache severity and attack frequency for vestibular migraine patients. METHODS: Sixty patients with vestibular migraine were enrolled. Thirty patients received botulinum toxin A treatment (B+ group) in addition to the oral medication, whereas 30 patients received only oral medication (B- group). Headache severity was evaluated with Migraine Disability Assessment Scale and vertigo severity was evaluated with Dizziness Handicap Inventory scale. Vestibular migraine attack frequencies in the last three months were also evaluated. RESULTS: There was a statistically significant decrement in mean Dizziness Handicap Inventory scores, Migraine Disability Assessment Scale scores and vertigo attack frequencies after treatment for all patients, B+ and B- group patients (p<0.001 for all). The mean Migraine Disability Assessment Scale score gains (p<0.001) and vertigo attack frequency gains (p= 0.003) were significantly higher in the B+ patients than B- patients. CONCLUSIONS: Both B+ and B- group patients exhibited significant improvement in vestibular migraine attack frequencies, Dizziness Handicap Inventory score and Migraine Disability Assessment Scale score values. However, botulinum toxin A application had a more pronounced effect for Migraine Disability Assessment Scale score gain and vestibular migraine attack frequency values, but not for Dizziness Handicap Inventory score gain values. Thus, botulinum toxin A application should be considered for vestibular migraine patients whose headache severity degrees are more profound. The oral medication type (propranolol, flunarizine or amitriptyline) did not differ in influencing the vestibular migraine attack frequency, Dizziness Handicap Inventory score gain and Migraine Disability Assessment Scale score gain values.

Effects of vestibular rehabilitation in the management of patients with and without vestibular migraine.

OBJECTIVE: Vestibular Migraine (VM) is the second most common cause in patients with vertigo. Patients with VM complain about vestibular symptoms during a headache attack or during the period between attacks. Vestibular Rehabilitation (VR), an exercised based therapy to treat dizziness and balance dysfunction has been shown to be effective in vestibular diseases. In this study, we aimed to assess the effect of VR for vestibular symptoms and quality of life in VM patients, and to compare the results with patients with vestibular disorders without migraine. METHODS: Sixty (60) patients who received VR treatment were divided into two groups: vestibular migraine group (30 patients) and non-migraine vestibular dysfunction group (30 patients). All patients received VR for 18 sessions and the program was completed in 1.5 months. Pre- and post-treatment Dizziness Handicap Inventory (DHI) scores, Vestibular Disorders Activities of Daily Living Scale (VADL) scores, the frequency of dizziness and headache, and Computerized Dynamic Posturography (CDP) scores were assessed and compared retrospectively. RESULTS: With VR in both the vestibular migraine group and vestibular dysfunction group, DHI score, VADL score, the frequency of dizziness and headache scores significantly impaired. Post-treatment CDP results were higher than pre- treatment results for both patient groups. CONCLUSION: With VR, a significant improvement was observed in subjective and objective balance assessment measurement. Vestibular Rehabilitation must be considered in patients who do not benefit from medical therapy or have limited benefit. LEVEL OF EVIDENCE: Level III (evidence obtained from well-designed controlled trials without randomization).

Postural control at posturography with virtual reality in the intercritical period of vestibular migraine / Controle postural à posturografia com realidade virtual no período intercrítico da migrânea vestibular

Abstract Introduction: Vestibular migraine is a condition that associates headache and vestibular symptoms. Objective: To evaluate body-balance with virtual reality posturography in vestibular migraine. Methods: A total of 26 patients in the intercritical period of vestibular migraine were compared by means of the Balance Rehabilitation UnitMT (Medical/Interacoustics) posturography with 30 controls, paired for age and gender. Results: There was no significant statistical difference (p = 0.121) in the limit of stability area (cm2) between the experimental group and the control group values. There were significant differences (p < 0.05) in the values of sway velocity (cm/s) in nine of ten evaluated sensory conditions and in the pressure center displacement area (cm2) values in eight of those ten sensory conditions in the comparison between the control group and the experimental group. Conclusion: Posturography with virtual reality can identify changes in the sway velocity and the pressure center displacement area, characterizing the inability to maintain postural control with and without visual deprivation in situations of visual conflict and vestibulovisual interaction,in the intercritical period of the vestibular migraine.

Resumo Introdução: A migrânea vestibular é um quadro clínico que associa cefaleia migranosa e sintomas vestibulares. Objetivo: Avaliar o controle postural à posturografia com realidade virtual no período intercrítico da migrânea vestibular. Método: Um total de 26 pacientes com migrânea vestibular no período intercrítico da afecção foram comparados comparados à posturografia do Balance Rehabilitation UnitTM (Medical/Interacoustics) a um grupo controle com 30 indivíduos hígidos pareados por idade e sexo. Resultados: Não houve diferença estatisticamente significante (p = 0,102) entre os valores da área do limite de estabilidade (cm2) entre o grupo experimental e o controle. Houve diferença significante (p < 0,05) nos valores da velocidade de oscilação (cm/s) em nove de dez condições sensoriais avaliadas e nos valores da área de deslocamento do centro de pressão (cm2) em oito destas dez condições sensoriais em comparação entre os grupos controle e experimental. Conclusão: A posturografia com realidade virtual pode identificar alterações da velocidade de oscilação e da área de deslocamento do centro de pressão, o que caracteriza a inabilidade para manter o controle postural com e sem privação da visão, em situações de conflito visual e interação vestibulovisual, no período intercrítico da migrânea vestibular.

Postural control at posturography with virtual reality in the intercritical period of vestibular migraine.

INTRODUCTION: Vestibular migraine is a condition that associates headache and vestibular symptoms. OBJECTIVE: To evaluate body-balance with virtual reality posturography in vestibular migraine. METHODS: A total of 26 patients in the intercritical period of vestibular migraine were compared by means of the Balance Rehabilitation UnitMT (Medical/Interacoustics) posturography with 30 controls, paired for age and gender. RESULTS: There was no significant statistical difference (p = 0.121) in the limit of stability area (cm2) between the experimental group and the control group values. There were significant differences (p < 0.05) in the values of sway velocity (cm/s) in nine of ten evaluated sensory conditions and in the pressure center displacement area (cm2) values in eight of those ten sensory conditions in the comparison between the control group and the experimental group. CONCLUSION: Posturography with virtual reality can identify changes in the sway velocity and the pressure center displacement area, characterizing the inability to maintain postural control with and without visual deprivation in situations of visual conflict and vestibulovisual interaction,in the intercritical period of the vestibular migraine.

Influência do diabetes mellitus na qualidade de vida de indivíduos com migrânea vestibular / Influence of diabetes mellitus on the quality of life of individuals with vestibular migraine

Introdução: qualidade de vida refere-se à percepção de um indivíduo sobre o seu estado físico, emocional e social. No âmbito físico, pode ser impactada negativamente por condições como migrânea vestibular e diabetes mellitus (DM). Objetivo: descrever a qualidade de vida em pacientes com migrânea vestibular, com e sem DM. Metodologia: trata-se de um estudo transversal, descritivo, retrospectivo e secundário, realizado com pacientes com migrânea vestibular, atendidos em uma clínica-escola de Salvador-BA. Foram coletados dados sociodemográficos e clínicos, incluindo o autorrelato de DM. A qualidade de vida foi avaliada por meio do Dizziness Handicap Inventory (DHI), cuja pontuação foi classificada, quanto ao grau de incapacidade, em "leve" (0 a 30 pontos); "moderado" (31 a 60 pontos) e "severo" (61 a 100 pontos). Foram realizados procedimentos estatísticos descritivos por frequência simples e absoluta, medidas de tendência central e dispersão. Resultados: a amostra foi composta por 41 indivíduos, dotados das seguintes características: a idade média foi 42,46 anos (DP = 13,83), predominância do sexo feminino (87,80%), com diabetes (51,21%), com ansiedade (58,54%) e sem depressão (90,24%). A pontuação média do DHI foi de 47,26 pontos (DP = 21,81), classificada como impacto moderado, sendo maior entre os não diabéticos, porém a ansiedade predominou entre os não diabéticos (60%). Conclusões: acientes com migrânea vestibular apresentaram prejuízo de grau moderado na qualidade de vida, e a presença de diabetes não ocasionou um pior impacto nesse parâmetro. Além disso, a presença de ansiedade foi mais prevalente entre os não diabéticos e pode ter refletido na pior pontuação no DHI observada nesse grupo.

Introduction: quality of life refers to an individual's perception of their physical, emotional, and social status, and it can be affected by conditions such as vestibular migraine and diabetes mellitus (DM). Objective: to describe the quality of life of patients with vestibular migraine, with and without DM. Methodology: this cross-sectional, descriptive, retrospective study conducted a secondary analysis of data collected from patients with vestibular migraine treated at a school clinic in Salvador-BA. Sociodemographic and clinical data were collected, including self-reported DM. Quality of life was assessed using the Dizziness Handicap Inventory (DHI), with scores used to classify the degree of impact of the disability as "mild" (0 to 30 points); "moderate" (31 to 60 points) and "severe" (61­100 points). Descriptive statistics were computed using simple and absolute frequency, or measures of central tendency and dispersion. Results: the sample consisted of 41 individuals, with a mean age of 42.46 years (SD = 13.83 years), who were predominantly female (87.80%), with diabetes (51.21%) and anxiety (58.54%), and without depression (90.24%). The mean DHI score was 47.26 (SD = 21.81), classified as moderate impact, and it was higher among non-diabetics. Anxiety was more prevalent among non-diabetics (60.00%). Conclusions: patients with vestibular migraine showed moderate loss of quality of life, and the presence of diabetes did not reflect a worse impact on this parameter. Anxiety was more prevalent among non-diabetics, which may explain why this group had the worst DHI score.

Subdiagnosis, but not presence of vestibular symptoms, predicts balance impairment in migraine patients - a cross sectional study.

BACKGROUND: Vestibular symptoms and balance changes are common in patients with migraine, especially in the ones with aura and chronic migraine. However, it is not known if the balance changes are determined by the presence of vestibular symptoms or migraine subdiagnosis. Therefore, the aim of this study was to verify if the migraine subdiagnosis and/or the presence of vestibular symptoms can predict balance dysfunction in migraineurs. METHODS: The study included 49 women diagnosed with migraine with aura, 53 without aura, 51 with chronic migraine, and 54 headache-free women. All participants answered a structured questionnaire regarding migraine features and presence of vestibular symptoms, such as dizziness/vertigo. The participants performed the Modified Sensory Organization Test on an AMTI© force plate. The data were analysed using a linear mixed-effect regression model. RESULTS: The presence of vestibular symptoms did not predict postural sway, but the subdiagnosis was a significant predictor of postural sway. Migraine with aura patients exhibited more sway than migraine patients without aura when the surface was unstable. Additionally, we found high effect sizes (ES > 0.79) for postural sway differences between patients with chronic migraine or with aura compared to controls or migraine without aura, suggesting that these results are clinically relevant. CONCLUSIONS: The subdiagnosis of migraine, instead of the presence of vestibular symptoms, can predict postural control impairments observed in migraineurs. This lends support to the notion that balance instability is related to the presence of aura and migraine chronicity, and that it should be considered even in patients without vestibular symptoms.