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Vestibular Migraine: A Diagnosis of Exclusion

Vestibular Migraines: 2020 Management Update
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Vestibular migraine affects about 1% of the population, and maybe even up to about 10% of all vertigo patients seen in the office, said Ilka Naumann, MD, of DMC Medical Group in Detroit, Michigan. But despite being a common presenting cause of dizziness, vestibular migraine remains fairly undiagnosed.

“Unfortunately there is not one test that confirms the diagnosis,” said Dr. Naumann. “But there are common points in the history hinting the diagnosis before any testing is done to rule out other conditions. Often the patients will have a personal or family history of migraines and have often perfectly normal hearing.”

The patients, she said, will often describe being sensitive to sound in general, but more so during an attack. It’s common for a vestibular patient to be completely asymptomatic between attacks, just like Ménière’s disease patients. Dr. Naumann said that patients may exhibit strong responses to caloric testing (vestibular hyperfunction) with otherwise relatively normal findings.

“Often it becomes a diagnosis of exclusion,” she said, noting that the strong overlap with Ménière’s disease can complicate things. “Often it takes a stepwise approach and peeling the ‘layers of an onion’ to get patients back to feeling balanced and well.”

It’s for this reason that Dr. Naumann finds an integrative approach to treatment essential.

“Just like with many conditions, patients have to participate in their care and change their lifestyle, addressing stressors and improving their diet and sleep. It takes balancing their entire life in addition to the medical management.”

And physicians still have some work to do on the medical management side.

“Many ENTs are not comfortable treating migraines, many neurologists treat vertigo with meclizine or refer back to ENT, and patients often don’t have a good understanding about vestibular migraine when there are no headaches involved,” Dr. Naumann said. “Raising awareness and understanding about the disease on both sides makes treatment successful, patients very happy, and doctors satisfied.”