Vestibular drop attacks in Ménière’s disease and its association with migraine

DOI: https://doi.org/10.1007/s00405- 020- 05890- 3

Abstract-Summary We explored the association of vestibular drop attacks (VDA) with or without migraine in patients with Ménière’s disease (MD) and compared with patients clas- sified as vestibular migraine (VM).

In the sample of 401 patients with VDA who did not experience headache, VM was diagnosed among 16.4% participants and migraine not associated with vertigo was experienced among 25.2% of the participants.

Severity of postural instability, ability to move, and ability to stand up from chair

differed among VDA baseline, VDA migraine and VM patient groups.

Syncope associated with VDA was noticed more frequently in VM group. The current study suggests that migraine is common in MD patients who experi-

ence VDA.

The coexistence of migraine increased the impact of complaints associated

with VDA.

Extended: The current study excluded patients with headache as it seems likely that in this group there is abundant non-diagnosed migraine patients [468] as VM is poorly known in medical practice [469, 470].

The current study evaluated whether the complaints spectra of VDA and migraine

differ between patients classified as MD.

We suggest that MD would contain in future a classification in that MD with

migraine would be included as a part of MD.

Introduction Migraine is overrepresented among patients with MD [471] and has been suggested to cause vertigo mimicking MD [472].

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2 Mechanisms

It was observed, however, that patients with VM/MD had poorer quality of life

and more frequent and severe vertigo attacks than patients with MD alone.

MD patients often complain of a sudden loss of balance, which are referred to as

vestibular drop attacks (VDA) [473].

Some patients with MD lose their consciousness in connection with VDA

[474–476].

Ishiyama and others [477] indicated that the incidence of migraine is high in MD

patients with VDA who had fallen in connection to VDA.

So far, no systematic studies have been carried out in MD patients with VM con-

cerning the functional derangement of the otolithic system.

We explored the association of VDA with or without migraine in patients

with MD.

Methods As the headache was quite common and also associated with vertigo spells, after initial analysis we excluded the MD patients with headache (n = 327) as it was evinced that part of them had non-diagnosed migraine.

The questionnaire encompassed disease specific and impact related questions, which included: (1) an oto-neurology questionnaire [478, 479]; (2) EuroQol EQ-5D-3L general health-related quality of life (HRQoL) measure [480]; (3) spe- cific questions on anxiety or nervousness and vitality taken from the general HRQoL instrument 15D [481]; and specific questionnaire on headache and migraine with their association to MD [482].

We classified VM based on recent classification of Bárány Society and the International Headache Society [483] in that the criteria for VM is based on associa- tion migraine with rotatory vertigo attacks.

The response options included: 0 = no impact, 1 = weak, 2 = moderate, 3 =

severe, 4 = very severe (falls).

The occurrence of rotatory vertigo with headache and migraine was assessed by

dividing the study sample into two groups.

This included: (a) those with no association or rare association; and (b) those with vertigo occurred with migraine moderately often, frequently and very frequently.

Results In pairwise comparison, there were statistically significant differences between VDA baseline and VDA migraine group (Z = 2.67, p = 0.008) and between VDA baseline and VM groups (Z = 3.324, p < 0.002).

In pairwise comparison, the VM group did not differ in postural instability from

VDA migraine group (Mann–Whitney U-test, Z = 1.89, p = 0.07).

In pairwise comparison, the patients with VM performed worse than patients

with VDA migraine (Mann–Whitney U-test, Z = 2.89, p = 0.004).

In pairwise comparison, the patients with VDA baseline differed from the VM group (p < 0.001) and also from VDA migraine group (p < 0.001) according to the Bonferroni test.

2.3 Comorbidities

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In pairwise comparison, there was a statistically significant difference only

between VDA baseline and VM groups (p = 0.018).

Discussion We explored the differences between VDA and VM among patients with MD.

The study results suggested that migraine and VM increased the occurrence and

complaint impact of MD having VDA.

Syncope, problems provoked with physical strain, vertigo character, motility problems, and hyperacusis were the factors contributed to discriminating the VM from VDA in MD patients, but the discriminatory power was relatively poor and not clinically useful.

Based on the present study, the associated migraine seems to further cause bur- den on the VDA but it remains unclear whether VM in MD is an independent disor- der or a continuum of a same disorder from vestibule-cochlear system to trigemino-vascular system or vice versa.

The association of migraine with VDA further reduces the HRQoL and in VM

the HRQoL was poorest as in our previous study in MD and VM [482].

Conclusions The current study evaluated whether the complaints spectra of VDA and migraine differ between patients classified as MD.

VDA was never experienced in 19.4% of the MD patients. The VDA, head movement induced vertigo, greater severity of postural instabil- ity occurred more frequently among patients with VM, although only few marginal differences between patient groups were observed.

In patients with VDA, HRQoL differed significantly between the VM and no-

headache and no migraine group.

We could not discern any complaints discriminating between VM and MD that

would allow reclassification of a patient to MD or VM.

Acknowledgement A machine generated summary based on the work of Pyykkö, Ilmari; Pyykkö, Nora; Manchaiah, Vinaya. 2020 in European Archives of Oto-Rhino-Laryngology.

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