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Migraine-Associated Vertigo

Vertigo, which is an illusion of movement in relation to the environment, is commonly experienced as part of a migraine headache.

Migraine is a disease characterized by periodic headaches, but patients often experience other symptoms, including dizziness. In some patients, dizziness can be the only symptom. The dizziness associated with migraines is called vertigo.

Vertigo is basically a sensation of a room spinning around you, while at rest. Nausea and sometimes vomiting is always associated with vertigo.

Motion sickness is a common migraine accompaniment as well. Most studies report about 50% of patients with migraines have motion sickness. Patients with migraine-associated vertigo often provide a long history of motion intolerance during car, boat, or air travel or all three. People with migraines are, in general, more sensitive to motion of the environment and to busy environments.

The symptoms of migraine-associated vertigo are variable and may feel like a room spinning at rest (true vertigo), a constant feeling of imbalance, and/or dizziness associated primarily when moving and not at rest. Symptoms directly associated with a migraine headache can occur prior to the onset of headache or during a headache.

Vertigo Without Headaches

It is also quite common to experience vertigo during a headache-free interval. As such, many patients who experience migraine-associated vertigo will experience dizziness as the main symptom even in the absence of a headache! In fact, most patients with migraine-associated vertigo have dizziness that occurs independently of the headache.

This last condition of someone experiencing vertigo without any headache confuses doctors and patients alike. It is far more common than thought and most of the time is a missed diagnosis and thereby a missed opportunity for treatment.

Prevalence of Migraine-Associated Vertigo

Reports indicate that 27-42% of all migraine patients report episodic vertigo. What is interesting is that about a third (about 36%) of these patients experienced vertigo during headache-free periods. The remainder experienced vertigo either just before or during the headache. The incidence of vertigo during the headache period was higher in patients with aura as opposed to those without aura.
Duration:

The vertigo symptoms may last for a few minutes or may be continuous for several weeks or even for months! In women, there is a strong association of dizziness occurring within the menstrual cycle.

The duration of the vertigo can also be quite variable. The frequencies of different durations of vertigo spells in migraine-associated vertigo are as follows:

o 7% experience vertigo for a duration of seconds.
o 31% experience vertigo for minutes to up to 2 hours.
o 5% have vertigo for 2-6 hours.
o 8% have vertigo for 6-24 hours.
o 49% experience vertigo for longer than 24 hours.

What Causes the Vertigo Associated with Migraines?

The most commonly accepted theory regarding the pathophysiology of migraine-associated vertigo is the Cortical Spreading Depression theory (CSD). Multiple authors propose that episodes of dizziness are similar to that of a migraine aura or are actually part of the aura.

But since only about 20% of migraine sufferers actually experience an aura, researches attribute the vertigo as part of a fluctuation of nerve cell ion channels. Recent understandings in a particular type of migraine – Familial Hemiplegic Migraine (FHM) have shown two genes responsible for controlling ion flow across nerve cell membranes.

These two genes affect changes in calcium, sodium and potassium channels. This alters the electrical conduction potentials of nerve cells. The result is a transient wave front that suppresses central neuronal activity. This depression spreads in all directions from its site of origin. These changes result in a reduction in cerebral blood flow in the areas of spreading depression.

Two authors have suggested that when dizziness is unrelated to headache, the dizziness occurs from the release of neuropeptides, including substance P, neurokinin A, calcitonin and gene–related peptide [CGRP]. No single hypothesis explains the headache or dizziness process in migraine at this time. Thus, the causes of the symptoms of migraine remain controversial.

Meniere’s Disease

There is another relatively common form of vertigo called Meniere’s Disease. Meniere’s Disease is not related to migraines at all. It has a classic triad of vertigo, hearing loss and tinnitus (ringing of the ears). The vertigo of Meniere’s Disease is frequently confused with migraine-associated vertigo.  Fortunately, the vertigo associated with the more common forms of migraines rarely have any hearing loss and also does not have much in the way of tinnitus.

Basilar Migraines

The is one ominous variant of migraine headaches called Basilar Migraines (or also known as Bickerstaff ‘s syndrome) which is a cross between a migraine and occasionally ends up in a stroke. Some features of Basilar Migraines include vertigo, hearing loss and tinnitus. Up to 80% of patients with Basilar Migraine have been reported to have sensorineural hearing loss.

So in the case of the Basilar Migraines, the vertigo might be indistinguishable from Meniere’s Disease during the headache-free intervals. Otherwise the presence of the headache would lend it toward the migraine component and should be treated as a migraine.

Clearly, Basilar Migraines are a more pernicious variety of migraine headache. Even though Basilar Migraines are classified as a sub-group of migraines, some believe that the stroke-like damage that is frequently associated with this group of headaches places it in a different category and should be treated very differently from the typical migraine.

Treatment

Unfortunately, the vertigo component of migraines is extremely resistant to standard treatment. The triptan class of drugs is relatively ineffective. Also, the standard anti-vertigo drugs like meclizine and phenergan also do not work well.

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Migraines: When Nausea Is As Bad As The Headache

For some people, the worst thing about a migraine is not the pain – it’s migraine nausea.

Nausea and vomiting are two very distressing symptoms accompanying migraines in some people. About 80% of migraine sufferers get nauseous, but only 30% actually throw up. In rare occasions, a person may vomit so many times they actually become dehydrated.

Most of the time, simply treating the migraine relieves the nausea. However, the nausea and vomiting may be so bad that it actually prevents a person from taking their migraine relief medications. When this happens the nausea only serves to prolong the agony.

There are two types of migraine nausea:

  • Nausea that’s caused by extreme pain from any source – whether it be from a headache, neck or back pain, or abdominal pain.
  • Nausea produced by the brain sending signals down the vagus nerve into the stomach causing acute queasiness.

In the first instance, standard anti-nausea medications may be used to relieve symptoms. These medications may be taken orally as pills – or in severe cases where someone just cannot hold down anything – as rectal suppositories.

Examples of standard anti-nausea medications include:

  • Phenergan (promethazine hydrochloride)
  • Thorazine (chlorpromazine)
  • Compazine (prochlorperazine)
  • Tigan (Trimetho-benzamide hydrochloride)
  • Reglan (metoclopramide hydrochloride)
  • Gravol (dimenhydrinate)

All of the above are available in suppository form except for Reglan.

One natural method that delivers real benefits is ginger. Taking ginger in the form of tablets or even a tea has been shown to alleviate some of the nausea accompanying a migraine, as well being effective for other conditions, including motion sickness, pregnancy and vomiting after surgery.

For the type of nausea primarily caused by the brain itself, the activity that causes the migraine also causes the nausea. This is where the “triptan” drugs are used.

Effects of Triptans on Migraine Nausea

Triptan drugs have become the primary migraine prescription medication used since the 1990’s. Examples of triptans include:

  • Imitrex (sumatriptan)
  • Maxalt (rizatriptan)
  • Amerge (naratriptan)
  • Zomig (zolmitriptan)
  • Axert (almotriptan)
  • Frova (frovatriptan)
  • Relpax (eletriptan)

A 2001 study comparing four of the triptans concluded that Maxalt and Zomig were more effective at relieving nausea associated with migraines than Imitrex or Amerge. Of course about a third to a half of the patients in the study got better in two hours based simply on the placebo effect.

This isn’t to say that triptan medications should be used to combat nausea in non-migraine situations. Triptan medications don’t directly affect the nausea itself – they work in alleviating the migraine – which in turn eases the nausea.

As with any oral medication, unless you can keep it in your stomach – it’s not going to do you much good. Of the above triptans, all come in oral forms, but some can be taken in ways other than swallowing a pill.

There are 5 possible triptan formulations available:

  • Standard oral tablet (all triptans)
  • Subcutaneous (under the skin) injection (Imitrex)
  • Quick dissolving oral tablet (sub-lingual) (Maxalt, Zomig)
  • Nasal spray (Imitrex, Zomig)
  • Rectal suppository (Imitrex)

For example, Imitrex comes as an injection, which is fast acting and relatively effective, but has a host of unpleasant side effects and is extremely expensive. Imitrex has recently become available as a nasal spray and also comes as a rectal suppository.

Zomig and Imitrex are the only two triptans that are available as nasal sprays. Sprays have the advantage of being rapidly absorbed and being quick acting – with relief coming as early as 15 minutes after use.
Zomig and Maxalt are also available as quick dissolving sub-lingual (under the tongue) tablets, doing away with any problems associate with swallowing.

The triptan formulations offering an alternative to swallowing a pill allows patients the opportunity to possibly abort a migraine attack at its onset. This is very reassuring to those migraine sufferers who frequently encounter nausea – especially vomiting.

Early administration of treatment, particularly the triptans, during a migraine attack is vitally important. The preferred method of taking conventional pills and tablets is perfectly reasonable – so long as the patient is able to swallow and keep the medication down long enough for absorption to take place.

However, in situations where nausea with or without vomiting is frequent or likely, alternate forms of the triptan medications should be carefully considered.

A Better Method

There is another option – a migraine cure. Cure the migraine and never worry about nausea or vomiting again.

Recent reports indicate migraine headaches can indeed be totally abolished – as a number of elite medical clinics catering to women have testified. Under their treatment protocols, migraines are completely eliminated in 80% of their patients.

These successes are limited to women only, as addressing a women’s hormones is the basis of the cure. Some clinics have published their treatment protocols and even made them available to the public.

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