In this new series, GPs will take you through a case history and associated details of a fascinating but often unrecognised disorder. To kick the series off, Dr Keith Hopcroft outlines vestibular migraine – or migrainous vertigo
A 45-year-old male complains of recurrent episodes of vertigo. You see from his notes that these have been attributed to viral labyrinthitis or possible benign positional vertigo (BPV).
It seems odd, though, that he should get repeated problems if these are truly viral. And the episodes aren't clearly triggered by certain movements, nor do they pass within seconds – which makes BPV unlikely.
You explore the history further and establish that each attack results in the patient lying in a darkened room – partly because this eases the symptoms but also because there is an accompanying dislike of bright lights and loud noise. He also mentions that some attacks seem to spark a pounding headache, with occasional vomiting.
This patient has vestibular migraine – also known as migrainous vertigo. An association between vertigo and headache has long been suspected, but difficult to establish – after all, both symptoms are common and so may co-exist by chance. However, the consensus seems to be that this is a genuine migraine variant, and quite a common one at that – in one study of patients with vertigo, 14% had vestibular migraine.
The characteristic pointers are episodes of spontaneous or positional vertigo lasting anything from seconds to days, associated with migrainous symptoms – such as headache, aura and phono/photophobia. The vertigo may occur before, during or after the headache – though a headache isn't always present.
The management is much the same as for most migraine, both in the acute episode and in terms of prevention. Anti-emetics are often required in the acute phase anyway, and some – like prochlorperazine – will also ease the vertigo.
Issues for the GP
Vestibular migraine has only relatively recently become established as a distinct clinical entity. This, plus the facts that the vertigo may predominate over other migrainous features and may precede or follow the headache, make it a diagnosis rarely considered in general practice. Certainly, it would be cavalier to make the diagnosis at first presentation – severe headache plus vertigo can signify an acute vascular event.
In patients with otherwise unexplained recurrent vertigo, consider vestibular migraine – especially if there are other migrainous features.
Some attacks can spark a pounding headache