Clinical Profile of Vestibular Migraine- Insights from a Retrospective Study

Abstract

Introduction

Vestibular migraine (VM) is a subtype of migraine characterized by recurrent episodes of vertigo or dizziness, often accompanied by nausea, light and sound sensitivity, and other vestibular symptoms. It primarily affects females at a 5:1 ratio, with episodes lasting from minutes to 72 h, occurring with or without headaches. VM is one of the more frequent causes of recurrent vertigo, affecting around 1% to 2.7% of the population.

Aim

To analyze the clinical profile of patients with vestibular migraine (VM) treated in a tertiary care center in South India.

Materials and Methods

This retrospective observational study reviewed 45 patients diagnosed with VM between January 1, 2021, and June 30, 2023, based on the International Classification of Headache Disorders (ICHD) criteria. Demographic data, clinical characteristics, and duration of hospital stay were analyzed.

Results

The study included 34 female participants (75.6%) and 11 male participants (24.4%), with an average age of 45.3 years. 82.2% of patients reported symptom onset with headache, while 17.7% reported vertigo as the first symptom. The majority experienced daily to weekly episodes of dizziness and headache. Auditory symptoms were reported by 88.8% of patients, with tinnitus being the most common (48.8%). According to pure tone audiometry, 32.5% of patients had sensorineural hearing loss. VM episodes were often associated with menstrual periods, with 61.7% experiencing migraine during menstruation. Psychiatric illness was the most common comorbidity (20%). Cervical vestibular evoked myogenic potential (cVEMP) testing revealed increased latency in 17.7% of the patients and asymmetry in 15.5%. Most patients (84.4%) required hospital admission, with an average stay of 4.5 days.

Conclusion

Vestibular migraine predominantly affects females and is frequently associated with auditory symptoms, menstrual cycles, and psychiatric comorbidities. Early recognition and multidisciplinary management are crucial for improving patient outcomes.

Introduction

Vestibular migraine was first described by Dieterich and Brandt in 1999, and since then, it has been recognized as a distinct subtype of migraine characterized by recurrent vertigo or dizziness [1]. It is indeed considered one of the more frequent causes of recurrent vertigo. It is estimated to have a prevalence ranging from approximately 1% to 2.7% of individuals [2]. Vestibular migraine (VM) is defined as recurring episodes of vertigo, disequilibrium, or impaired balance that can last from minutes to more than 72 h. These episodes can occur with or without a headache with a variety of other symptoms, including nausea, vomiting, sensitivity to light (photosensitivity), sensitivity to sounds (phono sensitivity), sensitivity to smells (Osmo sensitivity), mild subjective hearing loss, tinnitus, and a feeling of fullness in the ears. It primarily affects females at a ratio of 5:1 and is more common in people without aura. (female to male) [1]. Patients with VM often exhibit a normal physical examination between episodes [3]. Vestibular symptoms typically start to appear years after the illness, at which point headaches may cease or become less frequent [4].

This study aimed to analyze the clinical profiles of patients receiving treatment at the VM outpatient clinic.

Materials and Methods

This study Included all patients diagnosed with vestibular migraine (VM) between January 1, 2021, and June 30, 2023, at a tertiary care center in South India. Ethical committee approval was obtained prior to conducting the study.

1. Study design: Retrospective observational study

2. Study Population: Inclusion criteria required patients to be aged between 18 and 75 years and to have a confirmed diagnosis of VM based on the international classification of headache disorders (ICHD) criteria. Exclusion criteria included the presence of other significant vestibular disorders, such as vestibular neuritis, benign paroxysmal positional vertigo (BPPV), or Meniere's disease, as well as neurological conditions potentially impacting vestibular function or migraine presentation, such as multiple sclerosis or brain tumors.

3. VM diagnosis criteria in the appendix of the ICHD-3 beta version

1. Vestibular diagnosis

2. At least five episodes that meet the C and D requirements

3. Migraines, either current or past, with or without aura

4. Symptoms of vertigo range from mild to severe and last for five to seventy-two hours.

5. At least one of the following three migraine characteristics is linked to at least 50% of episodes:

6. a headache with at least two of the four features Unilateral; moderate to severe intensity; pulsating quality; aggravated by regular physical activity

7. b. Photophobia as well as phonophobia

8. Visual aura

9. E. This difference was not more satisfactorily explained by a different ICHD-3 diagnosis or vestibular disorder [4].

10. Data Collection: Demographic information, clinical characteristics, and duration of hospital stay were recorded. The clinical profile of each patient was assessed, including symptoms such as headache, vertigo, and auditory disturbances. Pure tone audiometry (PTA) was performed to assess hearing levels, and cervical vestibular evoked myogenic potential (cVEMP) testing was used to examine vestibular function.

11. Statistical analysis: Descriptive statistics were used to analyze demographic and clinical data. Qualitative data were expressed as frequencies and percentages, while quantitative data were analyzed using means and standard deviations. The chi-square test was used to examine associations between categorical variables, and a t-test was applied to compare means between groups. Statistical analysis was performed using SPSS software, version 19.

Results

The study comprised 45 patients who met the criteria for VM based on the International Classification of Headache Disorders (ICHD) criteria; 34 (75.5%) were female, and 11 (24.4%) were male (Fig. 1). The participants age ranged from 18 to 75 years, with an average age of (mean 45.3 years ± SD 13.6).

Fig. 1.

Gender distribution

As shown in Table 1, 37 patients (82.22%) reported headache as their first symptom, while 8 patients (17.77%) reported vertigo as their first symptom.

Table 1.

Symptom onset in patients with vm

First symptom	Headache	Vertigo
Number of patients	37	8
Percentage (%)	82.2	17.7

Almost all of the patients reported headaches and dizziness, with symptoms ranging from daily to monthly. On a daily to weekly basis, 62% of patients had dizziness, while 51% experienced headaches. (Table 2).

Table 2.

Distribution of symptoms frequency in patients with vm

Frequency of episodes	Headache	Dizziness
	No of patients (%)	No of patients (%)
Daily	12 (26.6)	13 (28.8)
Daily to weekly	23 (51.1)	28 (62.2)
Weekly to monthly	10 (22.2)	4 (8)

Of the 45 patients in the study, 40 reported having auditory symptoms associated with vestibular migraine. Tinnitus was the most commonly reported complaint among those with auditory symptoms, affecting 22 individuals (48.8%), with hearing loss accounting for 29%. (Table 3).

Table 3.

Distribution of auditory symptoms in patients with vm

Complaints	Number of patients, percentage (%)
Hearing loss	13 (28.8)
Tinnitus	22 (48.8)
Aural fullness	5 (11.1)
No symptom	5 (11.1)
Total	45 (100)

Forty patients (89%) underwent pure tone audiometry (PTA); 27 (67.5%) were normal, and 13 (32.5%) showed evidence of hearing loss, with sensorineural hearing loss (SNHL) (54%) being the most frequent finding in this study. (Table 4).

Table 4.

PTA findings in patients with vm

Type of finding	Right unilateral	Left unilateral	Bilateral	Total patients
Conductive hearing loss	1 patient	1 patient	1 patient	3 (23%)
Mixed hearing loss	1 patient	1 patient	1 patient	3 (23%)
SNHL	2 patients	5 patients	0	7 (54%)

All the 34 female participants experienced migraines or dizziness during menstruation. 62% of them reported migraines, and 20% noticed vertigo during menstruation. At the same time, 18% experienced both migraines and vertigo during menstruation. (Table 5).

Table 5.

Relationship of vm patients with menstrual cycle

Relation with menstrual cycle	Number of patients, Percentage (%)
Migraine with menstruation	21 (61.7)
Dizziness with menstruation	7 (20.5)
Both during menstruation	6 (17.6)

Among 45 individuals diagnosed with vestibular migraine, 37 (82.2%) had comorbidities, with psychiatric disorder (20%) being the most commonly observed in this study. (Table 6).

Table 6.

Distribution of comorbidities in patients with vm

Comorbidity	Number of patients, percentage (%)
Diabetes mellitus	6 (13.3)
Systemic hypertension	6 (13.3)
Chronic kidney disease	8 (17.7)
Psychiatric illness	9 (20)
Hypothyroidism	8 (17.7)
None	8 (17.7)

The cVEMP report was available to all patients. The cervical vestibular evoked myogenic potential (CVEMP) test revealed that 30 patients (67%) had normal cervical VEMP responses. Eight of them had increased delay, and seven had asymmetry. (Table 7).

Table 7.

Cervical vestibular-evoked myogenic potential results in patients withm

Cervical vemp	Number of patients, percentage (%)
Increased latency	8 (17.7)
Asymmetry	7 (15.5)
Normal	30 (66.6)

Out of 45 patients with VM, 7 were treated as outpatients, while 38 were admitted to the hospital. The hospital stay ranges from three to seven days, with an average of 4.5 days. (Table 8).

Table 8.

Duration of hospital stay in patients with vm

Mode of treatment	Number of patients, percentage (%)	Minimum duration of stay (days)	Maximum duration of (days)	Mean duration of stay (days)
Admission	38 (84.4)	3	7	4.5

The number of hospital visits by patients with vestibular migraine was calculated.Despite several symptomatic episodes, 67% visited the hospital less than 5 times, with a small number (4%) visiting more than 10 times. (Table 9).

Table 9.

Number of visits to the hospital in patients with vm

Number of visits to the hospital	Number of patients percentage (%)
1–5	30 (66.6)
5–10	13 (28.8)
> 10	2 (4.4)

Discussion

VM is a prevalent and challenging neurological condition characterized by periodic episodes of vertigo or dizziness combined with migraine symptoms. According to the studies, VM has a female prevalence [2, 3, 6], with a reported ratio of women to men of 3.7:1 [2, 6] between the fifth and sixth decades of life [2]. This study indicated that VM was most prevalent among women (76%), with an average age of 45.5 years. The gender ratio in the vestibular migraine study was around 3.1:1, with 34 female participants (76%) and 11 male participants (24.4%) out of 45 patients evaluated.

Migraines can begin up to 15 years before vertigo appears. However, patients who reported both symptoms appearing simultaneously tend to suffer an earlier age of onset for both conditions.[7] Patients who suffered migrainous vertigo had a history of classical migraine headaches earlier in their lives, but these migraines had diminished by the time the vertigo episodes began. [4]. Most patients describe that certain instances of dizziness are not linked in time to headaches or other symptoms of migraines. Furthermore, when dizziness and migrainous symptoms coincide, the temporal correlation can differ from one episode to another. Some patients experience vertigo attacks without ever developing a headache [8]. For most patients (82.22%) the onset of symptoms began with a headache, while the remaining patients (17.77%) experienced vertigo as the initial symptom. This highlights the importance of recognizing that vestibular migraine can manifest with different symptoms and may present with headache or vertigo as the initial complaint. The duration of vestibular migraine attacks varies widely. It can encompass brief periods lasting seconds to minutes, extending to hours or even days [8], and occurs with frequencies ranging from once a week to once a month and from once a month to once a year [2]. The frequency of symptoms was as follows: most patients reported experiencing both daily headaches and vertigo (26.6% and 28.8%, respectively), while a significant portion experienced symptoms ranging from daily to weekly (51.1% for headaches and 62.2% for vertigo).

During a migraine episode, the auditory system can be affected, potentially leading to hearing loss. Additionally, central sensitization, a phenomenon associated with migraines, can result in the brain processing of auditory signals abnormally, leading to symptoms such as tinnitus (ringing in the ears), otalgia (ear pain), aural fullness (a sensation of fullness in the ears), and phonophobia (sensitivity to sound) [2]. During vertigo, a subgroup of patients with definitive VM reported tinnitus (46.4%), ear fullness (34.5%), and hearing loss (25.7%) [2, 9]. Hearing loss is frequently the first cause of tinnitus, and it can also cause aberrant hyperexcitability and neural synchronization in the central auditory system [2]. This study confirms these findings, with tinnitus being the most common complaint (48.8%) and hearing loss being the most common complaint (28.8%). Aural fullness is more common in the VM group, and there are a few possible causes for this, such as central sensitization and low-frequency hearing loss [2].

PTA revealed that 16% patients exhibited sensorineural hearing loss (SNHL) with unilateral SNHL being more prevalent. Mild and reversible sensorineural hearing loss, primarily unilateral, was noted at low frequencies (125, 250, and 500 Hz).[2–6] VM can cause intermittent hearing loss, tinnitus, and aural pressure; however, unlike Meniere's disease (MD), hearing loss in VM usually does not progress to severe levels over time. These auditory characteristics aid in distinguishing vestibular migraine from MD, idiopathic sudden sensorineural hearing loss (SSNHL), and other vestibular disorders [2].

Hormonal fluctuations, especially during menstrual periods, have been implicated in triggering migraines in some individuals. In the majority of cases, migraines tend to occur during the week preceding and following menstruation and are often intense enough to persist for 1 to 2 days.[10] In this study, all the female patients reported a relationship between migraine, dizziness and menstruation. 37 (82.8%) had some comorbidity with vestibular migraine, of which psychiatric illness (20%) was most commonly reported in this study, followed by chronic kidney disease (17.7%), hypothyroidism (17.7%), diabetes mellitus (13.3%), and systemic hypertension (13.3%). The high prevalence of psychiatric illnesses raises important questions regarding the potential bidirectional relationship between vestibular migraine and mental health. It has also been demonstrated that many people are diagnosed with psychiatric-related illnesses (anxiety, sadness, sleeplessness, functional disorders, phobia) after developing vestibular symptoms [11].

Lofti et al. reported increased latency (P13) in patients with VM, whereas the amplitude asymmetry ratio was not significantly different between the two groups (VM patients and normal patients) [12]. The latencies to CVEMP (P13, P23) were shorter in the treated group than in the control group. In the same study, a clinically significant asymmetry ratio discrepancy greater than 35% was found for 48.69% of the patients [13]. In this study, the CVEMP results revealed that a considerable proportion of patients had increased latency (17.7%) and asymmetry (15.5%). Most patients (84.4%) required hospital admission to manage their symptoms, with an average duration of 4.5 days due to the distressing nature of the disease. Patients with VM frequently seek medical attention due to the recurrent nature of the condition. This study revealed that most patients (66.6%) made between 1 and 5 hospital visits, emphasizing the need for regular follow-up and ongoing management for improved outcomes.

Accurately diagnosing and managing VM requires understanding its clinical and epidemiological characteristics. We hope that this study addressed the numerous features of VM. However, the research's limitations include its retrospective design, which depends on records that may be incomplete and inaccurate, increasing the potential of recall bias. The small sample size limits statistical power and may not represent the full spectrum of VM presentations. Further research could investigate the pathophysiological mechanisms that relate vestibular symptoms to psychiatric diseases and hormonal imbalances.

Conclusion

This study concluded that VM is closely connected with female gender, headache is the first symptom that precedes vertigo, episodic symptoms appear on a weekly basis, menstruation and psychiatric illness might trigger the symptoms. The findings underscore the importance of early recognition, appropriate diagnostic evaluation, and multidisciplinary management to improve the quality of life for VM patients.

Author Contributions

All authors contributed to the research article. All authors read and approved the final manuscript.

Funding

No funding was received to assist with the preparation of this manuscript. The authors have no relevant financial or non-financial interests to disclose.

Declarations

Conflict of interest

Authors have declared that no competing interests exist.

Ethical Approval

Ethical committee approval was obtained to carry out this study.

Informed Consent

Informed Consent was obtained from the patient for investigations used in this manuscript.