Vertiginous headache encompasses patients with dizziness or vertigo as well as headache, even though the symptoms may not occur in an obvious temporal relationship. The type of dizziness experienced by patients is different from the heavy-headedness experienced during rhinogenic headache. Patients may have a personal or family history of typical or atypical migraine. They should be evaluated for possible Meniere syndrome, migraine headaches, and/or eye movement disorders. Management is directed to treatment of the underlying abnormality. Long-term follow-up of these patients is necessary, because further otologic abnormalities may present later.
Key points
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Vertiginous headache may occur with the headache and the dizziness symptoms may occur simultaneously or at seemingly unrelated times.
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Patients may have a personal or family history of migraine headaches, with or without aura, and their symptoms are often described as atypical Meniere syndrome.
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Patients with vertiginous headache are often intolerant to complex visual stimuli, such as busy market aisles, action or 3-D movies, and scrolling on the computer, and motion sickness is a frequent finding.
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Evaluation for Meniere syndrome, migraine headache, and ocular vergence abnormalities is helpful in patients with vertiginous headache.
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Treatment is directed toward the underlying problem and may include migraine medication, Meniere treatment, and/or vision therapy directed to vergence stability.
Overview
Headache and dizziness are vague words used to describe symptoms that can encompass a range of discomfort experiences, from mild head pressure to severe, debilitating head pain, and from light-headedness or heavy-headedness to feeling off-balance or experiencing true spinning vertigo. As learned from the time of Osler, careful, prompted history enables a patient help the physician determine the actual symptoms that the patient is experiencing and start to determine causality. The historical features of interest include duration of headache history, presence of vertigo or dizziness, frequency and length of headache or dizziness episodes, association of vertigo with either headache or the triggers or precipitants of the headache, aura, accompanying symptoms, and alleviating factors. Personal or family history of headache or migraine, use of medications, and social history, including ingestion of caffeine, nicotine, and salt, are important. There is evidence that vertigo in childhood is associated with migraine headaches in adulthood.
Migraine-Associated Vertigo
Approximately 13% of the adult population has migraine; of those, 27% to 42% report episodic vertigo, with more than one-third of them describing their vertigo as occurring during headache-free periods. These patients are also refractory to traditional vestibular rehabilitation and have been recently classified as having migraine-associated dizziness (MAD) or migraine-associated vertigo (MAV). Criteria for diagnosis of MAD are evolving, but frequently patients with episodic dizziness or vertigo have only a remote history of migraine headache or vice versa. Often, these patients report episodic dizziness and/or headache brought on by complex visual stimuli. Work-up can sometimes show unilateral vestibular hypofunction or abnormality on electrocochleography or vestibular evoked myogenic potential (VEMP) but often is normal. MRI often reveals findings, such as nonspecific white matter lesions, that are consistent with migraine. These dizzy patients who complain of intolerance to complex visual motion and who demonstrate normal vestibular function often fall into the category of MAD. A subset of these patients responds to migraine pharmacotherapy. Neuro-optometric examination of such patients frequently reveals a weakness of vergence ocular motility. In those patients, completion of a course of vision rehabilitation treatment (VT) can improve both symptoms and overall function.
Although the International Headache Society only recognizes vertigo as a component of basilar-type migraine, many studies have sought to better define the relationship between migraine and vertigo. A prospective study examining 200 patients from a dizziness clinic and 200 patients from a migraine clinic were compared with 200 age-matched and gender-matched controls from an orthopedic clinic. A statistically significant increase in the prevalence of migraine was demonstrated in the dizziness clinic group (38%) versus the orthopedic control group (24%). In contrast to visual vertigo patients, however, vestibular function tests, including caloric testing and dynamic posturography, often fail to demonstrate a vestibular weakness in MAV patients.
Motion Sickness
A lower threshold for motion sickness susceptibility has been shown in migraine patients. One study reported a history of motion sickness in 50% of migraineurs versus only 20% of tension headache sufferers. Motion sickness has been described as abdominal discomfort, dizziness, and headache occurring secondary to a neural mismatch between the visual system and the vestibular and/or proprioceptive systems. This mechanism is believed mediated at the level of the brainstem nuclei and the cerebellum. The connection between migraine and motion sickness tolerance was further delineated when it was shown that there was a statistically significant increase in photophobia, nausea, and duration of headache in migraine patients after optokinetic stimulation compared with normal controls.
Visual-Vestibular Mismatch
The noxious visual stimuli inciting dizziness in these patients include reading; scrolling on a computer screen; watching action footage on television or in the movies; seeing highly patterned objects, such as quilts or checkerboard designs; being in busy situations, such as a store; and switching gaze back and forth between a computer monitor and written material. This so-called supermarket syndrome was introduced in 1975 to describe a subset of patients with Meniere syndrome whose primary complaints were visual in nature. A later compilation of case reports highlighted the challenge of dizzy patients whose complaints were primarily nonrotational dizziness, blurred and double vision, and visual motion hypersensitivity and for whom there seemed no clear diagnosis and no treatment. Visual motion triggering or exacerbating dizziness has also been termed space and motion discomfort, visuo-vestibular mismatch, visual vertigo syndrome, and motorist disorientation syndrome. On vestibular testing, these patients may have negative results or may demonstrate chronic abnormalities. Although in some of these patients, incorporating visual desensitization to vestibular rehabilitation has demonstrated benefits in both subjective symptoms and postural stability, many others cannot tolerate or find benefit from vestibular rehabilitation.
Diagnostic Criteria for MAV
The currently accepted criteria for definite MAV include current or prior history of migraine with episodic vertigo accompanied by headache, photophobia, phonophobia, and visual or other auras. The criteria for probable MAV include current or prior history of migraine, migrainous symptoms during vertigo, migraine precipitants of vertigo more than 50% of the time (including food triggers, sleep irregularities, or hormonal change), and greater than 50% response to migraine medications.
Overview
Headache and dizziness are vague words used to describe symptoms that can encompass a range of discomfort experiences, from mild head pressure to severe, debilitating head pain, and from light-headedness or heavy-headedness to feeling off-balance or experiencing true spinning vertigo. As learned from the time of Osler, careful, prompted history enables a patient help the physician determine the actual symptoms that the patient is experiencing and start to determine causality. The historical features of interest include duration of headache history, presence of vertigo or dizziness, frequency and length of headache or dizziness episodes, association of vertigo with either headache or the triggers or precipitants of the headache, aura, accompanying symptoms, and alleviating factors. Personal or family history of headache or migraine, use of medications, and social history, including ingestion of caffeine, nicotine, and salt, are important. There is evidence that vertigo in childhood is associated with migraine headaches in adulthood.
Migraine-Associated Vertigo
Approximately 13% of the adult population has migraine; of those, 27% to 42% report episodic vertigo, with more than one-third of them describing their vertigo as occurring during headache-free periods. These patients are also refractory to traditional vestibular rehabilitation and have been recently classified as having migraine-associated dizziness (MAD) or migraine-associated vertigo (MAV). Criteria for diagnosis of MAD are evolving, but frequently patients with episodic dizziness or vertigo have only a remote history of migraine headache or vice versa. Often, these patients report episodic dizziness and/or headache brought on by complex visual stimuli. Work-up can sometimes show unilateral vestibular hypofunction or abnormality on electrocochleography or vestibular evoked myogenic potential (VEMP) but often is normal. MRI often reveals findings, such as nonspecific white matter lesions, that are consistent with migraine. These dizzy patients who complain of intolerance to complex visual motion and who demonstrate normal vestibular function often fall into the category of MAD. A subset of these patients responds to migraine pharmacotherapy. Neuro-optometric examination of such patients frequently reveals a weakness of vergence ocular motility. In those patients, completion of a course of vision rehabilitation treatment (VT) can improve both symptoms and overall function.
Although the International Headache Society only recognizes vertigo as a component of basilar-type migraine, many studies have sought to better define the relationship between migraine and vertigo. A prospective study examining 200 patients from a dizziness clinic and 200 patients from a migraine clinic were compared with 200 age-matched and gender-matched controls from an orthopedic clinic. A statistically significant increase in the prevalence of migraine was demonstrated in the dizziness clinic group (38%) versus the orthopedic control group (24%). In contrast to visual vertigo patients, however, vestibular function tests, including caloric testing and dynamic posturography, often fail to demonstrate a vestibular weakness in MAV patients.
Motion Sickness
A lower threshold for motion sickness susceptibility has been shown in migraine patients. One study reported a history of motion sickness in 50% of migraineurs versus only 20% of tension headache sufferers. Motion sickness has been described as abdominal discomfort, dizziness, and headache occurring secondary to a neural mismatch between the visual system and the vestibular and/or proprioceptive systems. This mechanism is believed mediated at the level of the brainstem nuclei and the cerebellum. The connection between migraine and motion sickness tolerance was further delineated when it was shown that there was a statistically significant increase in photophobia, nausea, and duration of headache in migraine patients after optokinetic stimulation compared with normal controls.
Visual-Vestibular Mismatch
The noxious visual stimuli inciting dizziness in these patients include reading; scrolling on a computer screen; watching action footage on television or in the movies; seeing highly patterned objects, such as quilts or checkerboard designs; being in busy situations, such as a store; and switching gaze back and forth between a computer monitor and written material. This so-called supermarket syndrome was introduced in 1975 to describe a subset of patients with Meniere syndrome whose primary complaints were visual in nature. A later compilation of case reports highlighted the challenge of dizzy patients whose complaints were primarily nonrotational dizziness, blurred and double vision, and visual motion hypersensitivity and for whom there seemed no clear diagnosis and no treatment. Visual motion triggering or exacerbating dizziness has also been termed space and motion discomfort, visuo-vestibular mismatch, visual vertigo syndrome, and motorist disorientation syndrome. On vestibular testing, these patients may have negative results or may demonstrate chronic abnormalities. Although in some of these patients, incorporating visual desensitization to vestibular rehabilitation has demonstrated benefits in both subjective symptoms and postural stability, many others cannot tolerate or find benefit from vestibular rehabilitation.
Diagnostic Criteria for MAV
The currently accepted criteria for definite MAV include current or prior history of migraine with episodic vertigo accompanied by headache, photophobia, phonophobia, and visual or other auras. The criteria for probable MAV include current or prior history of migraine, migrainous symptoms during vertigo, migraine precipitants of vertigo more than 50% of the time (including food triggers, sleep irregularities, or hormonal change), and greater than 50% response to migraine medications.
Diagnosis
A detailed and thorough history helps distinguish between vestibular and nonvestibular headache. Of particular importance in these individuals is a history of visually triggered vertigo and/or migraine. Much of what is known about this is derived from understanding of traumatic brain injury. Questions that should be asked specifically include the following: Are you able to be in a supermarket aisle without feeling dizzy? Are you able to watch handheld camera footage or 3-D movies? Do you feel worse when scrolling on a computer or reading for periods of time or switching between printed materials and a computer monitor? Do you have difficulty in highly patterned or visually stimulating circumstances? A personal or family history of migraine headaches or Meniere syndrome or dizziness/vertigo in childhood is helpful in determining MAV. Diagnostic criteria for definite and probable MAV are detailed previously.
Physical examination related to MAV and visual-vestibular dysfunction is a complete ear-nose-throat-head-and-neck examination and additional tests. A user-friendly tool is the 10-minute examination of the dizzy patient. It includes the following:
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Spontaneous nystagmus
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Gaze nystagmus
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Smooth pursuit
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Saccades
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Fixation suppression
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Head thrust
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Post-headshake nystagmus
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Dynamic visual acuity
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Dix-Hallpike test
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Static positional nystagmus evaluation
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Limb coordination
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Romberg stance
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Gait observation
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Specialized tests
Tests with which otolaryngologists are generally less familiar but that have a high rate of abnormality in MAV or visual-vestibular mismatch are screening tests of neuro-optometric function. These include the following:
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Vergence oculomotor motility, looking for disjunctive changes of eye position in depth (ie, along the Z axis), including convergence, divergence, supravergence, and infravergence ( Fig. 1 A)
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Versional ocular motility, examining conjunctive eye movements in a 2-D plane (ie, the X-Y plane), including fixation, saccades, and smooth pursuit ( Fig. 1 B)
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Accommodation: which is the ability to change focus while retaining the clarity of vision while looking from near to far and back again, due to a change in the crystalline lens of the eye ( Fig. 1 )
