前庭性偏头痛基因学研究进展

前庭性偏头痛是临床常见的良性复发性眩晕疾病，因其反复发作的临床特点、在人群中 的高发病率以及较差的药物治疗反应，严重影响了患者生活质量。作为一种遗传性疾病，前庭性偏头 痛的基因学研究对揭示其发病机制、开发诊断标记物及新型治疗手段有着重要的作用。现对前庭性偏 头痛的基因学研究进展加以综述，以期为今后前庭性偏头痛的临床诊疗提供参考。     

解读前庭性偏头痛诊断标准

头晕或眩晕与头痛是神经科学和耳鼻咽喉科学最常见的主诉之一.临床上有涉及头晕或眩晕与头痛交叉症状的患者,随着学科的发展进步,曾经先后被诊断为前庭性偏头痛、偏头痛相关眩晕、偏头痛相关性前庭病、偏头痛性眩晕等.这不仅是2个症状之间的交叉,还是2个学科之间的交叉.视觉、前庭觉和本体感觉共同作用以维系机体平衡,前庭外周刺激信号通过前庭感觉通路传递到中枢的过程中与头痛的相关通路有可能产生交互,病理状态下有可能引发头晕或眩晕合并头痛,临床上有可能为"一元"疾病,也可能是"二元"疾病共病,因而存在争议,引发关注.2012年中华神经科杂志组织青年医生进行了关于患者偏头痛合并眩晕时应诊断为前庭性偏头痛还是偏头痛性眩晕的辩论[1];在国际上,国际前庭学研究领域权威——Barany学会(为纪念因从事前庭学研究获1914年诺贝尔医学或生理学奖的奥地利学者Barany而命名)和国际头痛学会(IHS)共同探讨制定了前庭性偏头痛诊断标准,并于2012年在前庭研究杂志上发表[2].解读该诊断标准,同时了解与其进行鉴别诊断的相关头晕或眩晕疾病的特点及研究进展,将有助于我们在临床上对头晕或眩晕、头痛相关疾病的诊断和鉴别诊断.     

前庭性偏头痛磁共振成像研究进展

前庭性偏头痛是一种临床常见的表现为各种头晕 / 眩晕与前庭症状的疾病,发病机制尚 不明确,其患病率日益增高及反复发作严重影响患者的生活质量。作为临床一种常见的疾病,复杂的 临床表现及阴性的各项检查结果,使得临床医生对前庭性偏头痛的诊断仍有一定的困难。神经影像技 术的应用极大地加深了对前庭性偏头痛的认识。     

奥卡西平和卡马西平治疗前庭阵发症的疗效对比

<正>前庭阵发症是周围性眩晕的常见病因之一,主要表现为短暂性眩晕发作,发病机制可能为血管神经之间的压迫,目前临床采用抗癫痫药物治疗该病,常用药物为卡马西平,奥卡西平治疗前庭阵发症尚无报道,本研究就奥卡西平和卡马西平治疗前庭阵发症的疗效及不良反应进行比较分析,现报道如下。1材料与方法1.1诊断标准按照2008年Hufner等在Brandt诊断标准基础上提出的新的诊断标准:至少有5次眩晕发作,每     

前庭性偏头痛的研究进展

前庭性偏头痛作为一个特殊的临床综合征,日益受到众多神经内科医生的关注。目前对前庭性偏头痛的诊断标准及病理机制存在较大争议。长期反复的偏头痛或眩晕发作,其积累效应可引起颅脑结构及功能改变,同时也可能影响认知功能。功能磁共振技术的一大优势是可以早于脑部结构改变,及时发现许多亚临床阶段疾病的功能改变,利于早期诊断及制定治疗方案。文中就前庭性偏头痛的病理机制、诊断标准、临床特点、认知功能改变和功能磁共振研究进展予以综述。     

梅尼埃病与前庭性偏头痛的相关性研究进展

梅尼埃病和前庭性偏头痛是临床常见的两种疾病,临床表现相似,缺乏鉴别诊断的有力 手段。研究表明梅尼埃病和前庭性偏头痛在发病机制、临床特征及治疗方面存在一定的相关性。因此, 现从发病机制、临床特征、治疗方面对这两种疾病的相关性进行探讨。     

正确掌握前庭性偏头痛的诊断

"前庭性偏头痛"是早已被认识但最近方被国际头痛协会和国际Bárány学会认可的诊断概念。明确诊断前庭性偏头痛,首先需要熟悉诊断标准,其次需要掌握临床表现(如前庭症状性质、发作持续时间、伴随症状等),最后需要与前庭性偏头痛具有相似表现的疾病(如特殊类型偏头痛、良性发作性眩晕、良性复发性眩晕和梅尼埃病等)相鉴别。     

眩晕的药物治疗

本文讨论了眩晕及相关疾病的生理学和药物治疗。能够有效治疗眩晕的药物类型包括抗胆碱能药物、抗组胺药物、苯二氮卓类、钙通道拮抗剂和多巴胺受体拈抗剂。这些药物通常具有多种作用。它们可缓解症状发作的强度（如前庭抑制剂）或影响其潜在的疾病过程（如在前庭性偏头痛病例中使用钙通道拮抗剂）。其中大多数药物，特别是那砦具有镇静作用的药物，还具柯调节前庭损害代偿速度的作用。近几年来，这一因素显得越来越重要，因为现在经常推荐患者进行前庭康复性物理治疗以促进前庭功能代偿。因此，只有当治疗医师对所应用药物的药理学知识及其确切的药理学作用了如指掌时，才能进行最恰当的眩晕治疗。 眩晕有4大类病因，相应的病因有共特定的药物治疗方案。耳源性眩晕包括内耳疾病如Meniere病、前庭神经炎、良性发作性位置性眩晕（BPPV）和双侧前庭神经麻缚。对于Meniere病和前庭神经炎这2种疾病，前庭抑制剂如抗胆碱能药物和苯二氮卓类有效。对于Meniere病，限盐和利尿剂治疗可预防复发；对于前庭神经炎，现在仅推荐短期应用前庭抑制剂。对于BPPV和双侧前庭神经麻痹，目前并不推荐进行药物治疗，但物理治疗对两者非常有效。中枢性眩晕包括与偏头痛或某些卒中有关的眩晕。偏头痛柏关性眩晕的治疗主要依靠预防性药物，如L型钙通道拮抗剂、三环类抗抑郁药和β-受体阻滞剂。对于卒中患者或其他脑干或小脑器质性病变患者，推荐给予一种联合试用前庭抑制剂和物理治疗的折衷性治疗方法。精神性眩晕的发生与惊恐、焦虑性疾病和广场恐怖症有关。苯二氮卓类是最为有效的治疗药物。未确定的和原因不明的眩晕由其他许多诊断组成，对这些患者的处理建议采用经验性方法，试验性联合应用“全效药物”（如苯二：氮卓类，和住适当情况下停止试验性治疗）、物理治疗和心理咨询。     

前庭性偏头痛与焦虑 抑郁的相关性研究进展

前庭性偏头痛是一种以发作性前庭症状为主,伴偏头痛特征的顽固性头晕,是临床上最常见的复发性头晕病因之一,近年来研究热度较高。目前前庭性偏头痛的发病机制国内外尚未达成共识,正确诊断率不高,难治性前庭症状、头痛的反复发生易使患者出现焦虑、抑郁等负性情绪,严重影响患者的日常工作及生活,了解前庭性偏头痛与焦虑、抑郁之间的相关性可为临床诊治、提高患者生活质量提供部分参考。本文主要对前庭性偏头痛与焦虑、抑郁发病机制的关系进行综述。     

偏头痛性眩晕临床诊治的前瞻性研究

目的 探讨偏头痛性眩晕的临床特点,观察偏头痛性眩晕对偏头痛预防性药物治疗的反应.方法 前瞻性登记偏头痛性眩晕的患者,分析其人口学及临床特点,随访患者对偏头痛预防性药物治疗的反应.结果 偏头痛性眩晕患者以女性为主,眩晕起病与头痛起病平均相差12.72年,眩晕的持续时间及与头痛发作的关系各异,仅27.58%患者的眩晕满足ICHD-Ⅱ对偏头痛先兆的诊断标准.接受氟桂利嗪或多塞平治疗后,偏头痛性眩晕患者的眩晕发作频率及眩晕发作日明显下降.结论 眩晕与偏头痛发作之间的关系是主要的诊断依据.偏头痛预防性药物可能对偏头痛性眩晕的预防有效,其临床效用仍须进一步证实.     

Migrainous vertigo: development of a pathogenetic model and structured diagnostic interview

PURPOSE OF REVIEW: Vestibular symptoms occur frequently in patients with migraine. This review refines recently proposed diagnostic criteria for migraine-related vestibular symptoms, and develops a pathophysiological model for the interface between migraine and the vestibular system. RECENT FINDINGS: The epidemiological link between migraine and vestibular symptoms and signs suggests shared pathogenetic mechanisms. Links between the vestibular nuclei, the trigeminal system, and thalamocortical processing centers provide the basis for the development of a pathophysiological model of migraine-related vertigo. During the last year, several studies have increased understanding of the relationship between migraine and vestibular symptoms. A study of motion sickness and allodynia in migraine patients supports the importance of central mechanisms of sensitization for migraine-related vestibular symptoms. A study has demonstrated effective treatment of vertigo with migraine therapy. The identification of migrainous vertigo, however, is hampered by a lack of standardized assessment criteria for both clinical and research practices. The application of published criteria for the diagnosis of migrainous vertigo allows the development of a standardized, structured assessment interview. SUMMARY: An understanding of the relationship between migraine and the vestibular system increases knowledge of the pathogenesis of both migraine and vertigo. In addition, studies have identified successful treatment, with standard migraine therapies, of vestibular symptoms in patients with both migraine and vertigo. The use of a standardized assessment tool to identify this unique population of patients will help future studies to test both the pathological model and effective treatment options.     

Epidemiology of vertigo,migraine and vestibular migraine

Both migraine and vertigo are common in the general population with lifetime prevalences of about 16 % for migraine and 7 % for vertigo. Therefore, a concurrence of the two conditions can be expected in about 1.1 % of the general population by chance alone. However, recent epidemiological evidence suggests that the actual comorbidity is higher, namely 3.2 %. This can be explained by the fact that several dizziness and vertigo syndromes occur more frequently in migraineurs than in controls including benign paroxysmal positional vertigo, Meniere’s disease, motion sickness, cerebellar disorders and anxiety syndromes which may present with dizziness. In addition, there is increasing recognition of a syndrome called vestibular migraine (VM), which is vertigo directly caused by migraine. VM affects more than 1 % of the general population, about 10 % of patients in dizziness clinics and at least 9 % of patients in migraine clinics. Clinically, VM presents with attacks of spontaneous or positional vertigo lasting seconds to days. Migrainous accompaniments such as headache, phonophobia, photophobia or auras are common but not mandatory. Cochlear symptoms may be associated but are mostly mild and non-progressive. During acute attacks one may find central spontaneous or positional nystagmus and, less commonly, unilateral vestibular hypofunction. In the symptom-free interval, vestibular testing adds little to the diagnosis as findings are mostly minor and non-specific. In the absence of controlled studies, treatment of VM is adopted from the migraine sphere comprising avoidance of triggers, stress management as well as pharmacotherapy for acute attacks and prophylaxis.     

Diagnosis and treatment of the most frequent vestibular syndromes

The aims of this study were to identify the most common vestibular syndromes in a dizziness unit, and to observe their clinical aspects and response to treatment. Five hundred and fifteen patients were studied retrospectively in two institutions. Aspects of anamnesis, physical examination and the response to treatment were evaluated. The most frequent syndromes were: benign paroxysmal positioning vertigo (VPPB) (28.5%), phobic postural vertigo (11.5%), central vertigo (10.1%), vestibular neuritis (9.7%), Meniere disease (8.5%), and migraine (6.4%). A good response to treatment was observed in most patients with migraine (78.8%), VPPB (64%), vestibular neuritis (62%), Meniere disease (54.5%) and vestibular paroxismia (54.5%). On the other hand, patients with downbeat nystagmus and bilateral vestibulopathy had poor response (52.6% and 42.8%, respectively). The diagnosis of these most frequent vestibular syndromes were established through anamnesis and physical examination (with specific clinical tests for evaluation of the vestibular function). The correct diagnosis and adequate treatment are important since these syndromes may have a good prognosis.     

“Vestibular migraine”: effects of prophylactic therapy with various drugs

Vertigo is frequently associated with migraine, and sometimes it is the cardinal symptom. This type of migraine is called “vestibular migraine”, “migrainous vertigo”, or “migraine-associated vertigo”. Earlier findings on effective prophylactic medication for such migraine attacks and their clinical features are few and insufficient. Our aim was to study the influence of prophylactic therapy on this type of migraine and to specify its clinical features. In a retrospective approach 100 patients (median age 47 years, range 21–72 years) with definite or probable vestibular migraine [1] were divided into two groups: those with (74 patients) and those without drug prophylaxis (26 patients). They were then interviewed by telephone at least 6 months after beginning therapy. All patients receiving medical prophylaxis showed a decrease of duration, intensity, and frequency of episodic vertigo as well as nearly all its associated features (p < 0.01). The group without medical prophylactic therapy showed only a reduction of vertigo intensity. Only 39 % of the 100 patients met the current IHS criteria for a basilartype migraine [2]. Thus, we propose that a new category – “vestibular migraine” – should be added to the HIS criteria. Furthermore, our data show that prophylactic medication may be effective for treating vestibular migraine and its associated symptoms; therefore, patient’s response to medical therapy may provide guidance in the diagnostic process of vestibular migraine.     

Migraine-related vertigo: towards a distinctive entity

Both migraine and vertigo are common complaints. Although they may coincide by chance, there is growing evidence for a clinical entity of recurrent vestibular symptoms related to migraine. This syndrome implies a possible causal relationship although the pathophysiology of migraine-related vertigo has not been fully elucidated. A migrainous aseptic inflammation is thought to create a central sensitivity that spreads from the trigeminal to the vestibular system. Diagnostic criteria for migraine-related vertigo are proposed. Treatment is based on anti-vertiginous drugs for acute interventions and prophylactic measures as are taken for migraine headaches. Multicenter, prospective controlled studies are highly warranted.     

Migraine vestibulaire : critères diagnostiques. Document consensuel de la Société Bárány et de la Société internationale des céphalées

This paper presents diagnostic criteria for vestibular migraine, jointly formulated by the Committee for Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society (IHS). The classification includes vestibular migraine and probable vestibular migraine. Vestibular migraine will appear in an appendix of the third edition of the International Classification of Headache Disorders (ICHD) as a first step for new entities, in accordance with the usual IHS procedures. Probable vestibular migraine may be included in a later version of the ICHD, when further evidence has been accumulated. The diagnosis of vestibular migraine is based on recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms. Symptoms that qualify for a diagnosis of vestibular migraine include various types of vertigo as well as head motion-induced dizziness with nausea. Symptoms must be of moderate or severe intensity. Duration of acute episodes is limited to a window of between 5 minutes and 72 hours.     

Vestibular migraine pathophysiology: insights from structural and functional neuroimaging

Vestibular migraine (VM) has been increasingly recognized as a frequent cause of episodic vertigo, affecting up to 1 % of the general population, with female preponderance. Recently, both the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society have proposed original diagnostic criteria for VM, which have been included in the recent edition of the ICHD-3 beta version. VM diagnosis implies that vestibular symptoms are present during a migraine attack, with or without headache, in the absence of objectively demonstrated interictal vestibulopathy. Nevertheless, despite a growing body of literature, there is still an ongoing debate regarding whether VM origin is principally central or peripheral. However, during the past few years, the extensive application of advanced MRI techniques has contributed to significantly improve the understanding VM pathophysiology. Functional and structural abnormalities have been detected in brain areas involved in multisensory vestibular control and central vestibular processing in patients with VM. In this brief review, we will focus on these recent neuroimaging findings.     

Dizziness and headache: a common association in children and adolescents.

Vertigo has long been recognized by the clinician as a frequent accompanying symptom of the adult migraine syndrome. This association has not been so readily identified in the pediatric population, and, as a consequence, children undergo unnecessary evaluations. We reviewed the charts of all children and adolescents referred for vestibular function testing to the Balance Center at the Barrow Neurological Institute between July 1994 and July 2000 (N = 31). Items analyzed included age, gender, symptoms that prompted the referral, test outcomes, family medical history, and final diagnosis. The most common justification for vestibular testing referral was the combination of dizziness and headache. Other less common reasons were "passing out" episodes, poor balance, and blurred vision. Normal test results were obtained from 70% of patients (n = 22). The most common abnormal test outcome was unilateral vestibular dysfunction (n = 5). Bilateral peripheral vestibular dysfunction was present in three patients. One patient had central vestibular dysfunction. The final diagnoses were vestibular migraine (n = 11), benign paroxysmal vertigo of childhood (n = 6), anxiety attacks (n = 3), Meniere's disease (n = 2), idiopathic sudden-onset sensorineural hearing loss (n = 1), vertigo not otherwise specified (n = 1), familial vertigo/ataxia syndrome (n = 1), and malingering (n = 1); in five patients, no definitive diagnosis was established. The stereotypical patient with vestibular migraine was a teenage female with repeated episodes of headache and dizziness, a past history of carsickness, a family history of migraine, and a normal neurologic examination. Patients who fit this profile are likely to have migrainous vertigo. Consequently, a trial of prophylactic migraine medication should be considered for both diagnostic and therapeutic purposes. Brain imaging and other tests are appropriate for patients whose symptoms deviate from this profile.     

Neuro-otological features of benign paroxysmal vertigo and benign paroxysmal positioning vertigo in children: a follow-up study

BACKGROUND: Causes of benign episodic vertigo in paediatric age include benign paroxysmal vertigo of childhood (BPV) and benign paroxysmal positional vertigo (BPPV). OBJECTIVE: The aim is to review the clinical, audiological and vestibular findings in a cohort of children with BPV and in a group of children with BPPV and to highlight the differences useful to formulating a differential diagnosis. METHODS: Eighteen children, aged 4-9 years, consecutively examined for paroxysmal attacks of dizziness and/or vertigo attacks between January 2002 and December 2002 entered our study. The clinical characteristics of vertigo, presence of triggering factors, family history of migraine, presence of motion sickness, migraine and other accompanying symptoms were considered. Neurological, ophthalmologic, vestibular and auditory functions were assessed. RESULTS: Eight children suffered from BPPV and ten children from BPV. In the BPPV group, the vestibular examination was normal except for the Dix-Hallpike maneuver. Liberatory maneuvers were immediately effective in all patients and all remained symptom-free during the follow-up. In the BPV group, the vestibular examination was positive in 3 patients but none had positive Dix-Hallpike maneuver. All patients with BPV have a positive family history of migraine and seven had a history of motion sickness. In all, migraine was present one year before the vertigo symptoms, with a frequency of at least two migraine episodes a month. CONCLUSION: BPV differs from BPPV in terms of family history, clinical symptoms, otoneurological signs, therapy and clinical evolution. BPPV is characterized by specific otoneurological signs, and must be treated with liberatory maneuvers: neither medical therapy nor strict follow-up is needed.     

Migraine-related vertigo: Diagnosis and treatment

A comprehensive review of the neurotologic manifestations of migraine is presented, focusing on the most recent publications regarding the epidemiology, clinical presentation, pathophysiology, diagnosis, and management of migraine-related vertigo (MV). A strong association exists between vertigo and migraine, with MV being the most common cause of spontaneous (nonpositional) episodic vertigo. Symptoms can be quite variable among patients and within individual patients over time, creating a diagnostic challenge. MV generally presents with attacks of spontaneous or positional vertigo lasting seconds to days with associated migrainous symptoms. Operational diagnostic criteria have been proposed but are not included in the most recent International Headache Society classification of migraine. Better elucidation of the neurologic linkages between the central vestibular pathways and migraine-related pathways and the discovery of ion channel defects underlying some causes of familial migraine, ataxia, and vertigo have furthered the understanding of MV pathophysiology. Treatment of MV currently parallels that of migraine headache, as proper studies of optimal MV management are just beginning.