There are so many more of you this month than last, so it's encouraged me to change up the model a little bit more to really listen to your feedback and increase the sense of community and collaboration.
This month's journal club was focused on Vestibular Migraines and included information about epidemiology, (very broad) pathogenesis, clinical features, differential diagnosis, testing and management.
As I mentioned in the email, my Google literacy is....emerging and I am working on one screen (soon to change). I wasn't able to admit everyone and present at the same time, or see questions as they appeared in the chat, and they weren't addressed at the time- which I apologize. I figured in an effort to increase conversation, I will post the questions here with my responses, however I would love to have comments on this post with your thoughts/feelings/ input for not only these questions but vestibular migraines in general. Should this blog format prove to be ok but not ideal, I am working on a website that can hopefully get the ball rolling quite a bit. I have added all three meetings so far and will continue to update the google drive with slides, resources and articles and continue the email chain. Linked in this post is the recording for easier access, and I am working on a way to link the articles featured as well.
Here are the typed questions that were missed during the live session:
1- from L.P.: Is there a questionnaire that can be used to better rule in/rule out other disorders from vestibular migraine? I believe so. Attached are two articles about using the DHI to better characterize/identify vestibular migraine (Chari et al) and another about how DHI results may vary among patients with different types of migraines (Emer et al). These might help give us better clues about patients with vestibular migraine versus something else or patients with a history of migraine and dizziness but maybe the type of migraine they have is unrelated/ less characteristic of vestibular migraine. I think this could be an interesting revisited topic down the line.
2- also from L.P.: Is there a cut off age where vestibular rehabilitation may become less effective in the management of vestibular migraine?
From my experience working with geriatric populations, particular with vestibular and subclinical balance disorders I don't believe there is a cut off age per say, but in the Jacobson vestibular textbook "Balance Function Assessment and Management", there is a fantastic chapter about managing vestibular problems in older patients and it states that vestibular rehab doesn't become less effective, it just may take more sessions or have slower progress than a younger individual. Specific age cutoff is unknown to me but I can keep looking.
3- from S.R.: Is vertical nystagmus that may be seen in positional testing resolved with fixation? In my experience yes and no- it depends on if its from a central or peripheral origin. The home statement I use for central positional nystagmus/vertigo also comes from the Jacobson vestibular textbook pages 667-6709of the 3rd edition (It's truly my holy text and I nearly have read it cover to cover. I'd be starstruck to be frank) "the elicited nystagmus is typically vertical. In the absence of other findings the CPN is thought to be benign. In other individuals, the CPN may be seen in conjunction with up beating or down beating spontaneous nystagmus while seated... a more common form of CPV is migrainous vertigo and positional nystagmus. Spontaneous, positional or a combination of spontaneous and positional nystagmus can be seen during an acute migraine with associated symptoms of dizziness. In these cases, the nystagmus can be vertical, horizontal or torsional with different positional tests"
4- Also from S.R.: Is there a dominating theory that vestibular migraines may be the cause of motion sickness that persists into adulthood?
I am completely unaware of the answer to this, but am happy to dig in a bit and report back.
5- from M.K.- asked a clarifying question regarding hearing loss associated with vestibular migraines and Meniere's disease.
In Meniere's disease it is typically starting as a low frequency SNHL with progression into the high frequencies (it often flattens out) and crappy word recognition. Hearing loss tends to quickly surpass the mild mark. The hearing loss is typically in the affected ear, and if it progresses to bilateral Meniere's disease the hearing loss will follow suit. For vestibular migraines, the articles I reviewed suggested that any fluctuations in hearing loss are transient and largely subjective (difficult to capture) and are normal sloping to relatively mild SNHL bilaterally. Hearing loss is less likely to be as progressive and more likely to maintain symmetry.
6- Last, B.C. made a fantastic recommendation regarding seeking a diagnosis and I quoted her comment here: "Several years ago I worked with 2 Neuro-Otologists, one was very involved in Vestibular Migraine diagnosis management, while the other physician felt strongly that vestibular migraine was not a true condition. I think for patients it is important to get more than one medical opinion if they are suffering from vestibular disturbances that may be migraine related".
