Migraine and benign paroxysmal positional vertigo: an outcome study of 476 patients.

Abstract

To investigate whether migraine is more common in patients with benign paroxysmal positional vertigo (BPPV) than in the general population, the author conducted a retrospective study of 476 patients with BPPV seen over 12 years at a tertiary referral center. Records of patients with a confirmed diagnosis of BPPV followed for 1 to 7 years were reviewed. The typical history of BPPV and the characteristic torsional positional nystagmus were identified in all patients. A modified Epley maneuver was performed for all patients with posterior semicircular canal BPPV, with a 98% success rate. The survey consisted of detailed patient questionnaires and vestibular tests. Migraine and motion sickness were three times more common in patients with BPPV than in the general population. A family history of migraine (58.4%) and vertigo (44.9%) was also more common in patients than in a control group.

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Page 1

UNERI
814
ENT-Ear, Nose & Throat Journal ■ December 2004
Migraine and benign paroxysmal
positional vertigo: An outcome study
of 476 patients
ORIGINAL ARTICLE
From the Neurotology and Balance Center, Institute of Neurologic Sci-
ences, Marmara University, Istanbul, Turkey.
Reprint requests: Alev Uneri, MD, Bagdat caddesi, No: 519/6 Usakligil
Apt. Suadiye, Istanbul, Turkey. Phone: 90-216-399-5326; fax: 90-
216-399-9682; e-mail: cuneri@superonline.com
Alev Uneri, MD
Abstract
To investigate whether migraine is more common in pa-
tients with benign paroxysmal positional vertigo (BPPV)
than in the general population, the author conducted a
retrospective study of 476 patients with BPPV seen over 12
years at a tertiary referral center. Records of patients with
a confirmed diagnosis of BPPV followed for 1 to 7 years
were reviewed. The typical history of BPPV and the char-
acteristic torsional positional nystagmus were identified
in all patients. A modified Epley maneuver was performed
for all patients with posterior semicircular canal BPPV,
with a 98% success rate. The survey consisted of detailed
patient questionnaires and vestibular tests. Migraine and
motion sickness were three times more common in patients
with BPPV than in the general population. A family history
of migraine (58.4%) and vertigo (44.9%) was also more
common in patients than in a control group.
Introduction
Benign paroxysmal positional vertigo (BPPV), a problem
restricted to the inner ear, is the most common cause of
recurrent vertigo. The main diagnostic criteria of BPPV are
the presence of a nystagmus associated with some degree
of vertigo that is elicited by position changes of the head.
Displacement of calcite fragments from the degenerat-
ing otoconia into the semicircular canals is known to be
responsible for this process.1-3 In the majority of patients,
the posterior semicircular canal is affected, but other semi-
circular canals can also be involved.4 Most patients with
BPPV present no evident cause, although head trauma,
Ménière’s disease, and ear surgery have been accepted in
the literature as eliciting events.5,6
Migraine is a common cause of episodic vertigo and
disequilibrium. It has been reported that 26 to 33% of
patients with migraine experience true episodic vertigo.7-9
Only a few articles in the literature address the relationship
between migraine and BPPV.5,8,10,11
To assess the etiopathology of BPPV, the author at-
tempted to estimate the association between migraine
and BPPV. Additionally, family histories of migraine and
episodic vertigo were cross-examined to investigate a
genetic propensity.
Materials and methods
The study group consisted of 476 patients with BPPV
seen over a 12-year period at a tertiary referral center.
Records of patients with a confirmed diagnosis of BPPV
followed for 1 to 7 years were reviewed. Each patient
completed a detailed questionnaire summarizing the key
features of his or her complaints, migraine, motion sick-
ness, and family history of migraine and episodic vertigo
attacks. The presence of one or more attacks of vertigo
in first-degree relatives of the patients was accepted as a
positive family history for episodic vertigo. The criteria
of the International Headache Society (IHS)12 were used
for the diagnosis of migraine.
One hundred seventeen patients who were treated for any
other causes of dizziness or vertigo, or without a history
of vertigo or migraine, were established as a control group
for family history of migraine and episodic vertigo.
Videonystagmography (VNG) (Visual Eyes, Micromedi-
cal Technologies, Inc., Chatham, Ill.) with accompanying
videotape records were collected for all patients. A Dix-
Hallpike maneuver was done in each patient by VNG, and
the entire process was monitored. The presence of a burst
of rotary nystagmus, which is counterclockwise at the right
side and clockwise at the left side in the Dix-Hallpike test
and subsides within seconds, indicated a typical posterior
semicircular canal BPPV.5,13,14 Patients with horizontal and
anterior semicircular canal variants of BPPV and other
types of positional nystagmus were excluded.
Results
The medical follow-up of the 476 study patients, aged 12
to 85 years (mean: 41.55 + 6.7 years), lasted 1 to 7 years
(mean: 3.8 years). Each patient was seen at least twice.
Three hundred thirty-five of the patients (70.4%) were
female and 141 (29.6%) were male.

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Volume 83, Number 12
815
MIGRAINE AND BENIGN PAROXYSMAL POSITIONAL VERTIGO: AN OUTCOME STUDY OF 476 PATIENTS
Two hundred sixty-one patients (54.8%) had a history
of migraine headaches, 321 (67.4%) reported motion
sickness, 278 (58.4%) had a positive family history of
migraine, and 214 (44.9%) had a positive family history
of episodic vertigo.
The Dix-Hallpike maneuver with VNG revealed that 276
cases (58%) of posterior canal BPPV were right-sided and
200 (42%) were left-sided. A modified Epley15 maneuver
was performed for all patients with posterior canal BPPV,
with a 98% success rate.

Discussion
BPPV is the most common cause of vertigo in adults and
has a female preponderance.4,16 The typical attack of BPPV
is usually a self-limited condition, and many cases resolve
spontaneously.
Dix and Hallpike described classic characteristics of
BPPV in 1952.5,13,14 It was initially thought to be a unique
condition caused by the presence of cellular debris in the
posterior semicircular canal. However, BPPV is now
considered a vestibular end-organ disorder caused by the
otoliths detaching from the maculae and floating as free
particles in the vestibular endolymphatic space.3,4,17 Other
semicircular canals also may be affected, and more than
one canal can be involved simultaneously.3,4,17
Migraine is a complex, usually inherited, neurologic
disorder in which headache is but one of the symptoms.18
Epidemiologic studies report that 18% of women and 6%
of men in the United States have migraine.19 Although
the majority of migraine sufferers do have headaches, mi-
graine can also occur without headaches. Under the IHS
classification,12 this is described as migraine aura without
headache. Particularly in middle-aged or older adults, the
aura may become the predominant feature of the migraine
attack with little or no headache.20
The vertigo that has been associated with migraine in
adults is more difficult to classify. The clinical association
of dizziness and migraine has been noted since the 1873
publication by Liveing.21 It is still difficult to prove a causal
relationship between migraine and any of the transient
symptoms that may accompany it. In 1926, Bramwell and
McMullen noted that many neurologic symptoms associ-
ated with migraine headache, including episodic vertigo,
might also occur without headache.22
Only a few articles in the literature address the rela-
tionship between migraine and BPPV.5,8,10,11 Ishiyama et
al theorized that patients with migraine suffer recurrent
damage to the inner ear (because of vasospasm or some
other mechanism), which predisposes them to recurrent
bouts of BPPV.5
In the author’s series, 54.8% of the patients had a history
of migraine headaches. This is three times the incidence
in the general population and correlates with the series
reported by Ishiyama et al.5 Of patients with migraine, 26
to 60% have a history of severe motion sickness, compared
with 8 to 24% of individuals in the general population.8
The author found motion sickness in 67.4% of patients in
the present study.
In this series, 36 of 476 patients (7.6%) were first-degree
relatives; 58.4% had a family history of migraine; and 44.9%
had a family history of episodic vertigo. These percentages
were also higher than those reported by the control group:
12.6% reported a family history of migraine, and 18%
reported a family history of episodic vertigo.
These data indicate that there may be a causal connection
between migraine and BPPV.
Acknowledgment
The author thanks Ayfer Kucukmentin, AS, for her skill-
ful work.
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