Total caloric eye speed in patients with vestibular migraine
Introduction
Vestibular migraine (VM), also known as migraine associated dizziness and other similar monikers, is a disease based on diagnostic criteria without any known characteristic findings on diagnostic testing [1]. While T2 hyperintensities on MRI can be seen in some migraineurs, this is a nonspecific finding [2], [3], [4]. Balance testing, which can include caloric testing, rotary chair testing, Dix-Hallpike evaluation, oculomotor assessment, posturography, and vestibular evoked myogenic potential (VEMP) testing has not previously been shown to result in any characteristic finding in patients with VM. In contrast, benign paroxysmal positional vertigo (BPPV), Meniere's syndrome, and superior canal dehiscence demonstrate robust and characteristic findings on balance testing.
Vestibular migraine has received increased recognition as a common cause of dizziness over the last 20 years [5], [6], [7], [8], [9] and is estimated to have a prevalence of about 1% in the general population and up to 19% in those presenting to the neurotology clinic [10], [11]. Some of the symptoms of VM can be similar to those seen in BPPV patients including sensitivity to head motion, rolling over in bed, and generalized imbalance, particularly among the elderly. As BPPV by its nature is not always active, a negative Dix-Hallpike test cannot reliably exclude BPPV in such patients. The identification of an objective finding in VM patients would aid in diagnosis and help better characterize the pathophysiology of vestibular migraine.
This study evaluated eyes speed in VM patients for several reasons. First, it has been noted [12], [13], [14] that patients with VM tend to be sensitive to vestibular testing and caloric irrigation in particular. Some VM patients vomit after a caloric stimulus, refuse to complete the caloric testing before all 4 irrigations are performed, or develop an attack or exacerbation of vestibular migraine for hours or days after balance testing. Second, the authors had noted anecdotally that some patients with vestibular migraine seemed to have either notably high or low total eye speeds. Third, caloric eye speeds are relatively easy to collect, and since most centers that offer balance testing have caloric evaluation, it was felt that a diagnostic criterion utilizing caloric stimulus would have the broadest applicability and largest utility for physicians treating dizziness.
Section snippets
Population under study
After obtaining approval from Saint Louis University Institutional Review Board, a retrospective chart review was performed on 140 patients with vestibular dysfunction and/or migraine who received electronystagmography (ENG) caloric testing and clinical evaluation at a tertiary dizziness clinic between 2004 and 2016. For patients who received multiple tests, the first date of testing closest in temporal relation to the initial presentation office note was selected as a zero time.
Data extracted
Results
Out of 136 patients reviewed, 44 patients were included in final analyses as they met both inclusion and exclusion criteria (Table 1), thirty-four patients (77%) were identified as having VM with ten patients (21%) having non-migraine related dizziness, as diagnosed by the principal physician (AAM). All of those included in the final cohort with non-migraine related dizziness had BPPV. Three patients with Meniere's disease were excluded from the final analysis due to its high association with
Discussion
This study showed a tendency for vestibular migraine patients to have lower TES than non-migraine related dizziness, namely below 79 deg/s. In the second quartile, the control group had significantly higher TES than VM (Fig. 2). This is a result in apparent contradiction to the fact that only VM patients were found in the first quartile, a rather strong statistical signal. Given the small group of patients in each quartile, the authors assume that the higher TES noted in the second quartile
Conclusion
We have demonstrated that while some patients with VM have low TES on caloric testing, these values are not uniformly low enough to differentiate themselves from than non-migraine dizzy patients on caloric testing. This suggests that caloric testing can be a diagnostic marker for helping to identify some patients with VM if TES is below 79 deg/s. Further research into objective measure to characterize patients with VM remains warranted.
Conflicts of interest
None.
Financial support
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Acknowledgments
The authors thank Dave Harris, PhD, CCC/A for his technical expertise in vestibular testing.
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