Braz J Otorhinolaryngol.

2016;82(4):397---402

Brazilian Journal of

OTORHINOLARYNGOLOGY
www.bjorl.org

ORIGINAL ARTICLE

Vestibular migraine: clinical and epidemiological

aspects夽
Ligia Oliveira Gonçalves Morganti ∗ , Márcio Cavalcante Salmito,
Juliana Antoniolli Duarte, Karina Cavalcanti Sumi, Juliana Caminha Simões,
Fernando Freitas Ganança

Department of Otorhinolaryngology and Head and Neck Surgery, Universidade Federal de São Paulo (UNIFESP), São Paulo, SP,
Brazil

Received 21 May 2015; accepted 17 June 2015

Available online 29 October 2015

KEYWORDS Abstract
Vestibular migraine; Introduction: Vestibular migraine (VM) is one of the most often common diagnoses in neurotol-
Vertigo; ogy, but only recently has been recognized as a disease.
Migraine disorders; Objective: To analyze the clinical and epidemiological profile of patients with VM.
Dizziness Methods: This was a retrospective, observational, and descriptive study, with analysis of
patients’ records from an outpatient VM clinic.
Results: 94.1% of patients were females and 5.9% were males. The mean age was 46.1 years;
65.6% of patients had had headache for a longer period than dizziness. A correlation was
detected between VM symptoms and the menstrual period. 61.53% of patients had auditory
symptoms, with tinnitus the most common, although tonal audiometry was normal in 68.51%.
Vectoelectronystagmography was normal in 67.34%, 10.20% had hyporeflexia, and 22.44% had
vestibular hyperreflexia. Electrophysiological assessment showed no abnormalities in most
patients. Fasting plasma glucose and glycemic curve were normal in most patients, while the
insulin curve was abnormal in 75%. 82% of individuals with MV showed abnormalities on the
metabolism of carbohydrates.
Conclusion: VM affects predominantly middle-aged women, with migraine headache represent-
ing the first symptom, several years before vertigo. Physical, auditory, and vestibular evaluations
are usually normal. The most frequent vestibular abnormality was hyperreflexia. Most individ-
uals showed abnormality related to carbohydrate metabolism.
© 2015 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published
by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://
creativecommons.org/licenses/by/4.0/).

夽 Please cite this article as: Morganti LOG, Salmito MC, Duarte JA, Bezerra KC, Simões JC, Ganança FF. Vestibular migraine: clinical and

epidemiological aspects. Braz J Otorhinolaryngol. 2016;82:397---402.

∗ Corresponding author.

E-mail: ligia og@yahoo.com.br (L.O.G. Morganti).

http://dx.doi.org/10.1016/j.bjorl.2015.06.003
1808-8694/© 2015 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
398 Morganti LOG et al.

PALAVRAS-CHAVE Migrânea vestibular: aspectos clínicos e epidemiológicos

Migrânea vestibular;
Resumo
Vertigem;
Introdução: Migrânea vestibular (MV) corresponde a um dos mais frequentes diagnósticos em
Transtornos de
otoneurologia, o que justifica a importância de seu estudo, embora tenha sido apenas recente-
enxaqueca;
mente reconhecida como entidade nosológica.
Tontura
Objetivo: Analisar os perfis clínico e epidemiológico dos pacientes atendidos em um ambu-
latório de migrânea vestibular.
Método: Estudo retrospectivo, observacional e descritivo, com análise de prontuários dos
pacientes do ambulatório de MV.
Resultados: O ambulatório é composto por 94,1% de mulheres e 5,9% de homens, com média
de idade 46,1 anos. O tempo de cefaleia foi superior ao de vertigem em 65,6% dos pacientes.
Observou-se correlação entre os sintomas e o período menstrual. A maioria (61,53%) dos
indivíduos apresentou algum sintoma auditivo, sendo o zumbido o mais frequente, emb-
ora a audiometria tenha sido normal em 68,51%. A vectoeletronistagmografia apresentou-se
normal em 67,34%, enquanto 10,20% apresentaram hiporreflexia e 22,44% hiperreflexia vesti-
bular. Exames eletrofisiológicos não mostraram alterações na maioria dos pacientes. Glicemia
de jejum e curva glicêmica foram normais para a maioria dos pacientes, enquanto a curva
insulinêmica mostrou-se alterada em 75% dos indivíduos. 82% dos indivíduos com MV apresen-
taram alguma alteração relativa ao metabolismo dos carboidratos.
Conclusão: Migrânea vestibular acomete, predominantemente, mulheres de meia idade, com
cefaleia migranosa e vertigem, sendo a primeira de instalação mais precoce. O exame físico
no período intercrise, bem como as avaliações auditiva e vestibular, mostram-se, geralmente,
normais. O tipo de alteração vestibular mais observado foi a hiperreflexia labiríntica. A maioria
os indivíduos avaliados apresentou alterações relativas ao metabolismo dos carboidratos.
© 2015 Associação Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado
por Elsevier Editora Ltda. Este é um artigo Open Access sob uma licença CC BY (http://
creativecommons.org/licenses/by/4.0/).

Introduction triggers for migraine headache, such as menstrual period,

irregular sleep, stress, physical activity, dehydration, and
certain foods and drinks, in addition to intense sensory
The association between migraine and vestibular symptoms
stimulation.6,8
has been known for a long time, and became more evident
Diagnostic criteria for VM were proposed by Neuhauser in
after a systematic study carried out in 1984 by Kyan and
20014 and revised in 2012 by Bárány Society, together with
Hood.1
the International Headache Society, which included it in an
Migraine and vertigo are common clinical conditions that
appendix in 2013, of the third edition of the International
affect, respectively, 14% and 7% of the general population.
Classification of Headaches, as a first step to identifying new
Their simultaneous occurrence would be 1%, if occurring
entities (Figure 1).9,10
at random. However, recent epidemiological studies indi-
The physical examination of patients with vestibular
cate that 3.2% of the population have both migraine and
migraine is usually normal between crises. During disease
vertigo.2,3 This can be attributed to two factors: vertigo
episodes, however, there is often spontaneous or positional
syndromes (Meniere’s disease, benign paroxysmal positional
nystagmus, with characteristics of peripheral or central
vertigo, and dizziness related to anxiety), which are more
involvement.6,11 Vectoelectronystagmography is generally
common in migraineurs when compared to controls; and
normal, with unilateral labyrinthine hypofunction reported
vestibular migraine (VM).2---4
in up to 20% of cases.6,12 Hearing assessment, likewise, is
Vestibular migraine is an entity first described in 1999
normal in most patients.6 Due to labyrinthine alterations, it
by Dieterich and Brandt5 and corresponds to a variant
is necessary to exclude other otoneurological diagnoses.
of migraine whose main symptoms are vestibular. VM is
The aim of this study was to analyze the clinical and
more common in individuals without aura, and affects
epidemiological profile of patients treated in the vestibular
predominantly women, at a frequency of up to 5:1.4,6 Ves-
migraine outpatient clinic of the Otoneurology Service of
tibular symptoms typically occur several years after the
the Discipline of Otology and Neurotology of the Depart-
disease onset, when headache may be less frequent or
ment of Otorhinolaryngology and Head and Neck Surgery,
even absent.2,4 The onset of vestibular symptoms replac-
Universidade Federal de São Paulo (UNIFESP).
ing the headache is more commonly seen in perimenopausal
women.7
The temporal association between migraine symptoms Methods
such as headache, photo and phonophobia, and the vesti-
bular symptoms is variable, even in the same individual.6 This was a cross-sectional, observational, and descriptive
VM episodes can be triggered by the same factors considered study, carried out at the vestibular migraine outpatient
Vestibular migraine 399

1. Vestibular migraine Table 1 General aspects of symptoms in patients with ves-

A. At least 5 episodes with vestibular symptoms of moderate or severe tibular migraine.
intensity, lasting 5 min to 72 hours.
B. Current or previous history of migraine with or without aura n % p-Value
according to the International Classification of Headache Disorders
(ICHD)9 Concomitant occurrence of dizziness and headache
C. One or more migraine features with at least 50% of the vestibular symptoms
episodes:
o headache with at least two of the following characteristics: Yes 48 67.6 <0.001
one sided location, pulsating quality, moderate or severe pain Sometimes 13 18.3
intensity, aggravation by routine physical activity
No 10 14.1
o photophobia and phonophobia,
o visual aura
Distribution of vertigo frequency in patients with
D. Not better accounted for by another vestibular or ICHD diagnosis9
vestibular migraine
2. Probable vestibular migraine Daily 17 22.1
A. At least 5 episodes with vestibular symptoms of moderate or severe Daily to weekly 35 45.5
intensity, lasting 5 min to 72 hours Weekly to monthly 13 16.9 <0.003
B. Only one of the criteria B and C for vestibular migraine <1×/month 12 15.6
C. Not better accounted for by another vestibular or ICHD diagnosis9
Correlation between migraine and menstrual period in
Figure 1 Diagnostic criteria. patients with vestibular migraine
Lempert T, Olesen J, Furman J, Waterston, Seemungal B, Carey Yes 25 80.6 <0.001
J, et al. Vestibular migraine: Diagnostic criteria Consensus doc- No 6 19.4
ument of the Bárány Society and the International Headache Correlation between vertigo and menstrual period in
Society. Rev Neurol (Paris). 2014;170:401---6. patients with vestibular migraine
Yes 11 61.1 >0.005
No 7 38.9
clinic of the Discipline of Otology and Neurotology of
the Department of Otorhinolaryngology and Head and
Neck Surgery of Universidade Federal de São Paulo
(UNIFESP). Most patients experienced episodes of dizziness more
Patient records were selected from the VM outpatient often than once a week (Table 1).
clinic, since its creation in February of 2011 to June of Headache worsening during the menstrual period was
2013. reported by most female patients. The same could be
Patients were analyzed according to epidemiological observed in relation to dizziness, although it was not sta-
data, such as gender, age, profession, and nationality, in tistically significant (Table 1).
addition to the clinical characteristics of the disease, previ- Forty-eight of 78 patients (61.53%) reported some audi-
ous medical history, and laboratory, auditory, and vestibular tory symptoms, and some reported more than one symptom
test results. This study was approved by the Research (Table 2).
Ethics Committee of the Universidade Federal de São Paulo Fifty-four patients underwent tonal audiometry, which
(UNIFESP) (No. 19615313.13.5.0000.5505). was normal in 37 (68.51%) individuals. Sensorineural hearing
Statistical tests were selected according to the data pro- loss was the most frequently observed alteration (Table 3).
file: the Kruskal---Wallis test was used to compare more than Vectoelectronystagmography was performed in 49
two variables, simultaneously; the Mann---Whitney test was patients and was normal in most individuals. Among the
used to compare variables in pairs; and the two-sample test changes, vestibular hyperreflexia was the most frequent,
for equality of proportions was used to assess whether the as shown in Table 4.
proportion of answers of two variables or levels was signifi- The brainstem evoked response audiometry (BERA) was
cant. shown to be altered in two (10.5%) of 19 patients who under-
The 95% confidence intervals (95% CI) and p < 0.05 were went the examination. In both, the alteration consisted of
accepted for all analyses. SPSS v. 17, Minitab v. 16, and Excel an increase in the electrophysiological threshold.
Office 2010 were used for the statistical analysis. The cervical vestibular-evoked myogenic potential
(VEMP) was assessed in 17 patients, and alterations were
observed in three (17.6%) (Table 5).
Results

Of the total of 85 patients, 80 (94.1%) were women and five Table 2 Distribution of auditory symptoms in patients with
(5.9%) were men, with ages ranging from 19 to 79 years --- a vestibular migraine.
mean of 46.1 years and a median of 47 years.
The time until symptom onset is shown in Figure 1. The Complaint n %
symptom of headache appeared, on average, 7.3 years ear- Hearing loss 14 17.94
lier when compared to dizziness. It was also observed that Tinnitus 41 52.56
65.6% of patients had had headaches for a longer period Ear fullness 23 29.48
when compared to vertigo. No complaint 30 38.46
It was observed that headaches and dizziness occurred Total 78 100
concomitantly in most patients, as shown in Table 1.
400 Morganti LOG et al.

Table 3 Pure tone audiometry findings in patients with vestibular migraine.

Type of finding n % Right unilateral Left unilateral Bilateral

n % n % n %
CHL 1 1.85 1 1.85 0 0 0 0
MHL 3 5.55 0 0 2 8.33 1 1.85
SHL 13 24.07 0 0 2 8.33 11 20.37
Normal 37 68.51
Total 54 100
CHL, conductive hearing loss; MHL, mixed hearing loss; SHL, sensorineural hearing loss.

Table 4 Vectoelectronystagmography findings in patients with vestibular migraine.

Type of finding n % Right unilateral Left unilateral Bilateral

n % n % n %
Hyporeflexia 5 10.20 1 2.04 1 2.04 3 6.12
Hyperreflexia 11 22.44 2 4.08 3 6.12 6 12.24
Central 0 0 0 0 0 0 0 0
Normal 33 67.34
Total 49 100

Of 81 patients, 49 (60.4%) had some comorbidity, among

Table 6 Distribution of comorbidities in patients with ves-
which systemic arterial hypertension (SAH) was the most
tibular migraine.
prevalent (Table 6). Four records lacked this information.
Regarding the metabolic evaluation, glucose and insulin Comorbidity n %
curves were requested for all individuals without a diagnosis SAH 26 32.09
of diabetes mellitus. For those known to be diabetics, fasting Others 26 32.09
glucose measurement was requested. Dyslipidemia 16 19.75
Information on fasting glucose of 57 patients, with and Depression 10 12.34
without diabetes, was obtained. Of these, 71.92% showed Diabetes mellitus 6 7.40
normal and 28.08% had altered values (p < 0.001). Values Hypothyroidism 6 7.40
between 100 and 125 mg/dL (impaired glucose tolerance) Epilepsy 3 3.70
were observed in 21.75%, while 7.01% had fasting blood glu- No comorbidities 32 39.5
cose greater than 125 mg/dL (diabetes mellitus).13 Total 81 100
Fifty-three patients, all without a prior diagnosis of dia-
betes mellitus, underwent the test after intake of 75 g SAH, systemic arterial hypertension.
of dextrose. After 120 min, 77.4% of the subjects had
normal blood glucose levels (<140 mg/dL and >55 mg/dL); values, whereas 25.5% had normal results (p < 0.001),
22.6% had altered results (p < 0.001) --- 11.32% (n = 6) show- according to the Kraft criteria.14,15 Hypoinsulinism (insulin
ing decreased glucose tolerance (140---199 mg/dL) and 5.6% <50 ␮U/mL in all measurements) was observed in 17 (39.5%)
(n = 3) individuals had diabetes mellitus (blood glucose above individuals. The sum of the values at 120 and 180 min was
200 mg/dL).13 Three individuals (5.6%) had glucose levels greater than 60 ␮U/mL in seven (16.27%) patients (Kraft
<55 mg/dL (hypoglycemia) at 120 min.13 type II curve). The means of these values were, respectively,
Insulin curve was assessed in 43 patients, also without a 64.3 ␮U/mL and 23.4 ␮U/mL.14,15 Eight tests showed delayed
diagnosis of diabetes mellitus. Of these, 74.5% had abnormal insulin peak, at 120 or 180 min (Kraft type III curve).14,15
In total, 82.22% of the patients had some carbohydrate
metabolism alteration, considering diabetes, hypoglycemia,
Table 5 Distribution of cervical vestibular-evoked myo- decreased glucose tolerance, hypoinsulinism and occult dia-
genic potential results in patients with vestibular migraine. betes, according to Kraft’s criteria.
Cervical VEMP n %
The mean values for glucose, insulin, hemoglobin, lipids,
and creatinine are found in Table 7.
Increased latency 0 0
Altered asymmetry index 3 17.64
Normal 14 82.35 Discussion
Total 17 100
This cross-sectional study assessed the characteristics of
VEMP, vestibular-evoked myogenic potential.
patients with vestibular migraine. There was a higher
Vestibular migraine 401

Table 7 Metabolic assessment of patients with vestibular migraine.

Laboratory Mean Median CV (%) Min Max n CI
Hb 13.6 13.6 7 11.7 16.5 57 0.2
LDL 109.9 111 33 39.2 195 57 9.4
HDL 53.7 55 29 31 110 57 4.1
Triglycerides 121.7 107 52 32 309 57 16.5
Fasting blood glucose 94.9 90 16 75 149 57 4.0
30 143.0 134 29 76 289 48 11.8
60 130.2 117 41 65 298 47 15.2
90 112.7 101 49 58 356 47 15.6
120 114.9 100 50 53 371 49 16.0
180 83.8 78 50 36 312 45 12.3
Glycated Hb 6.6 6.05 27 5.6 11.1 8 1.3
Fasting insulin 7.7 4.9 111 0.27 40.7 46 2.5
30 63.3 50.4 98 2.6 403.3 44 18.2
60 62.7 46.07 85 2.2 244.8 45 15.6
90 59.2 37.1 103 1.13 246.8 44 17.9
120 64.3 34.95 104 4.25 341.0 44 19.8
180 23.4 11.08 127 2.16 156.6 43 8.8
Creatinine 0.71 0.71 24 0 1.01 38 0.05
Hb, hemoglobin; LDL, low-density lipoprotein; HDL, high-density lipoprotein.

prevalence among women, mainly between the fifth and hypofunction, 4% bilateral hyporreflexia, and the same value
sixth decade of life (mean 46.1 years), corroborating liter- for bilateral hyperreflexia after a follow up of nine years.18
ature data.2---4,6 The later onset of vertigo symptoms, when Regarding the electrophysiological assessment, both the
compared to headache, was also confirmed.2,3,6 BERA and VEMP were normal in most individuals.
Dizziness appeared, on average, seven years after the A higher prevalence of hypothyroidism was found in
pain onset. The worsening of headache during the menstrual this sample (7.4%) when compared to the Brazilian gen-
period, well known among women diagnosed with migraine eral population (1.5%)19 (p < 0.001). For all other assessed
(50---60% of the cases), was also observed in the present comorbidities --- hypertension, dyslipidemia, depression,
sample.16,17 The same occurred with the correlation dizzi- diabetes, and epilepsy --- there were no statistically signifi-
ness vs. menstrual period. However, for the latter, there cant differences.20---22
was no statistical correlation, which may be due to the small Most VM patients had normal fasting glucose, as well
sample size, or due to the onset of vertigo after menopause as normal values at 120 min after administration of 75 g of
in many patients.6 dextrose.13 However, the insulin curve showed an alteration
Most patients reported concomitant occurrence of in 75% of subjects.14,15
headache and vertigo, and isolated symptoms occurred in VM has been only recently described, and its diagnosis
14%. In these cases, migraine equivalents such as photo and is purely clinical. The presence of symptoms that are
phonophobia or aura must accompany vestibular episodes common to other neurotological diseases, associated with
in at least 50% of the episodes in order to characterize the absence of an objective test, makes its diagnosis
VM. Otherwise, it can be defined as probable vestibular challenging.
migraine.4,9,10 It was found that 77% of the individuals Alterations in glycemic and/or insulinemic curves of
reported episodes of VM more than once per week. individuals without a specific diagnosis can lead to overes-
Auditory symptoms were observed in 61.53% of the sub- timation of metabolic alterations as the primary cause of
jects, with the tinnitus representing the main complaint. vestibular dysfunction. The error can also be supported by
However, the auditory assessment by pure tone audiome- the good response of the individual to clinical treatment,
try was unaltered in 68.51% of patients. Hearing loss, when which includes dietary recommendations and the practice of
present, was predominantly sensorineural, bilateral, sym- physical activities. It is known, however, that such measures
metric, descending, and mild. Similar findings were reported are part of the first line of the prophylactic treatment of
by Radtke et al., who attributed to VM a much slower hearing vestibular migraine, which could explain symptom improve-
loss when compared to that observed in Meniere’s disease.18 ment in patients who receive this kind of recommendation.
Vestibular assessment through vectoelectronystagmog-
raphy was, in most cases, normal, in accordance with
literature findings.6,18 The most frequently observed alter- Conclusion
ation, however, was bilateral vestibular hyperreflexia,
followed by unilateral hyperreflexia. Some authors have Vestibular migraine affects predominantly middle-aged
mentioned unilateral labyrinthine hypofunction as the most women with a history of migraine headache and vertigo,
frequent alteration.6,18 Radtke et al. found 16% unilateral with the first showing an earlier onset. Physical examination
402 Morganti LOG et al.

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