Benign paroxysmal vertigo of childhood: a long-term follow-up

We examined clinical aspects of Benign Paroxysmal Vertigo (BPV) in infancy and its most frequent differential diagnosis, in particular analogies and differences with forms of "migrainous vertigo" (MV) of later onset. During a long-term follow-up of 7 cases of BPV, diagnosed according to the Basser criteria, 5 of 7 BPV cases spontaneously resolved and 6 of 7 patients later developed migraine and other migraine-related symptoms. This course differs from that described for MV only in the age of onset of headache and in the chronological relationship with vertigo. The authors suggest that BPV can be interpreted as a migraine precursor and MV as a migraine equivalent.     

Posterior headache as a warning symptom of vertebral dissection: a case report

Cervicocerebral arterial dissection is an important cause of stroke in young adults; the onset is often characterised by severe occipital headache, followed by nausea, vomiting and vertigo, mimicking a migraine attack. We describe herewith a case of vertebral arterial dissection with cerebellar infarction, which started with a posterior headache and neurovegetative symptoms, without other signs. Recommendations for recognition of similar cases, potentially dangerous and treatable, are discussed.     

The point prevalence of dizziness or vertigo in migraine--and factors that influence presentation

Objective.— To ascertain and characterize the point prevalence of dizziness or vertigo in migraineurs presenting for routine appointments at a specialty headache clinic. Background.— Migraine, dizziness, and vertigo are all common in the general population, affecting 13%, 20‐30%, and 5‐10% respectively. Thereby, chance concurrence of migraine with either dizziness or vertigo would be expected in roughly 4% of the general population. It is the authors' clinical impression that severe attacks of migraine are far more commonly associated with these complaints than chance would predict. Methods.— This is a prospective, cross‐sectional study of 462 consecutive patients who presented for consultation at a specialty headache clinic over a 4‐month period of time. During routine check‐in procedures, patients were asked to report their headache pain on a 1‐10 Likert scale. Patients were also asked to report if they were currently experiencing dizziness or vertigo. Responses to these questions were recorded along with vital signs. Diagnosis of migraine with or without aura was made by headache medicine specialists in accordance with International Classification of Headache Disorders – second edition criteria. Chi‐square analysis was used to examine the prevalence of vertigo or dizziness in subjects with varying intensity of headache, and by history of aura. Results.— Of the 425 evaluable subjects, 28% experienced aura. Subjects' average age was 43.8 years (range 15 to 76 years); 89.5% were female. At the time of evaluation, 72.4% of subjects reported some degree of ongoing headache pain and 15.7% reported concurrent dizziness or vertigo. The prevalence of dizziness or vertigo was twice as high (24.5% vs 12.1%) in migraine with aura compared to migraine without aura (P < .01), and prevalence increased with age (P < .05). There was a strong correlation between migraine pain and subjective complaint of vertigo (P < .001). When migraine pain was present at an intensity of 7 or greater (on a scale of 1‐10), almost half of the subjects (47.5%) reported concomitant dizziness or vertigo. Conclusions.— Subjective complaints of dizziness or vertigo appear to be relatively common accompaniments of migraine, particularly migraine with aura, and prevalence increases with age. Disequilibrium symptoms have a strong and positive association with the severity of migraine pain. With co‐occurrence higher than expected by chance, the relationship either reflects comorbidity or these symptoms may be part of the migraine presentation. With a point prevalence of 15.7%, and factors that link expression both to the intensity of migraine pain and to migraine aura, the authors believe that the true relationship may prove to be the latter.     

Unusual headache syndromes in children

Headaches represent one of the most common reasons why children and adolescents seek medical attention and are the primary reason that they are referred to pediatric neurology practices. The most common headache syndromes diagnosed are migraine, tension-type, and chronic daily headache, and the bulk of recent medical literature regarding headache in children has focused on these clinical entities. Children are prone to have unusual headache syndromes, most of which fall under the category of "primary headache," most notably as manifestations of migraine with aura. Included within this group are basilar-type and hemiplegic migraine. The most intriguing subset included in the International Headache Society's classification system is the so-called "periodic syndromes of childhood that are precursors to migraine." These syndromes, quite peculiar to children, present a wide variety of episodic symptoms, including movement disorders, vomiting, ataxia, and vertigo, and may not include headache at all. This article provides an overview of some of the more unusual headache syndromes in children and adolescents.     

Basilar Artery Migraine: a Follow-up Study of 82 Cases

SYNOPSIS
82 adolescent or adult patients in whom the diagnosis of basilar artery migraine (BAM) had been made or suspected were reviewed. When rigorous criteria were used, the diagnosis could be confirmed in 49 patients (32 women and 17 men). Seven other patients probably had BAM, but did not totally fulfill the criteria. In 26 cases reevaluation did not confirm the diagnosis.
In the 49 patients with definite BAM the age of onset ranged from 10 to 62 years, 65% of them having their first attack in the second or third decade. 40% had BAM attacks only, while 60% had additionally other types of migraine attacks. A typical pattern of attacks with an "ischemic" aura followed by predominantly occipital headache was found in only 57%. The most frequent "ischemic" symptom was bilateral visual impairment (86%). Symptoms and signs of brain stem dysfunction were vertigo (63%), gait ataxia (63%), bilateral paresthesia (61%), bilateral weakness (57%), and dysarthria (57%). 77% of the cases had disorders of consciousness (mainly syncope, confusion and prolonged amnesia). 4 patients (8%) had epileptic seizures during the migraine attacks. 73% had a family history of migraine and 12% of epilepsy. EEG's were always abnormal during the attacks with predominantly localized or generalized mostly paroxysmal slow wave activity. CT scans were normal except for 2 women with repeated BAM attacks, who were smokers and taking contraceptive drugs, and who during an attack experienced a cerebellar and an occipital lobe infarction respectively. Of the 26 patients in whom the diagnosis of BAM could not be confirmed 13 had other types of migraine, while the remaining cases had temporal lobe epilepsy, intermittent vertebral basilar artery insufficiency, orthostatic hypotension or hysterical attacks.     

Vertigo, Motion Sickness and Migraine

SYNOPSIS
The frequency of vestibular symptoms in 104 headache patients during the headache-free phase was studied. The group was comprised of 84 patients with migraine (24 classical and 60 common) 12 with tension and 8 with cluster headache. Fifty-four headache-free subjects served as controls. All the participants filled out a vestibular symptom questionnaire.
Patients with classical migraine reported significantly more vestibular symptoms than the controls. Specifically they had more dizzy spells (r = 0.002) and vertigo episodes (r = 0.01) not associated with the headache. They also had more frequent motion sickness spells. Of the classical migraine patients reporting motion sickness 87% experienced it at least once in 6 weeks compared to only 11% of the controls. Classical migraine patients also probably have an especially "sensitive" vestibular system, as evidenced by increased tendency to visual vertigo (r = 0.005) and significantly increased dizziness when they themselves were spinning.
The common migraine patients showed a tendency to vestibular impairment that was not statistically significant. Recent findings of vestibular function abnormalities in this group may suggest an evolving dysfunction that is not yet symptomatic. Patients with tension and cluster headache did not differ from the controls in all the vestibular symptoms studied.
In summary, our findings indicate clearly a vestibular impairment in classical migraine. The relation to "benign recurrent vertigo," problems in the relationship of the occurrence of motion sickness to migraine and the possible mechanism causing the vestibular dysfunction are discussed.     

Migraine-associated Dizziness

We reviewed the clinical histories, examinations and results of quantitative vestibular testing in 91 patients with migraine-associated dizziness. Nausea and vomiting, hypersensitivity to motion and postural instability accompanied the dizziness. In the majority of patients, the temporal profile of the dizziness was more typical of the headache phase of migraine than of the aura phase. Nineteen patients (20.9%) had unilateral hypoexcitability to caloric stimulation, which represents a modestly increased risk of damage to the peripheral vestibular apparatus. We propose two separate pathophysiologic mechanisms for the production of dizziness with migraine: Short-duration vertiginous attacks lasting minutes to 2 hours and temporally associated with headache are due to the same mechanism as other aura phenomena (spreading wave of depression and/or transient vasospasm). Longer-duration attacks of vertigo and motion sickness lasting days, with or without headache, result from the release of neuroactive peptides into peripheral and central vestibular structures, causing an increased baseline firing of primary afferent neurons and increased sensitivity to motion.     

Sometimes Jello Helps: Perceptions of Headache Etiology, Triggers and Treatment in Literature

SYNOPSIS
Throughout history writers have attempted to describe the symptoms and evoke the misery of "a dismal headache."Writers from Plato to Stephen King have used the phenomenology of headache to illustrate their work. Lewis Carroll, for example, vividly describes the central scotoma, tunnel vision, phonophobia, vertigo, distortions in body image, dementia and visual hallucinations that often accompany migraine.
Although many authors have discussed the topic seriously, others have addressed the issue in a dismissive and even contemptuous manner, relegating this very real disorder to the status of a medical stepchild. We will examine headache etiology, triggers and treatment and explore the attitudes toward headache and headache sufferers found in literature.
We have recently seen a growing understanding of the physiological basis of headaches. However, this knowledge has not yet reached the level of literature or popular culture. In an age when it seems every Sunday night brings a new "disease of the week" movie, and every human ill is subjected to often intense and numbing scrutiny by the media, the anguish of a chronic migraine sufferer will probably remain unexplored - unless she kills her husband and children during an attack.     

Psychological Aspects of Weekend Headache Sufferers in Comparison with Migraine Patients

Sometimes the relaxation after stress may trigger a migraine attack. This is the principle that underlies that particular variant of migraine called "weekend headache". We hypothesize the presence in weekend headache prone subjects of a particular psychological background, different from that of common migraine sufferers. In order to detect possible differences supporting our hypothesis, we studied 104 new outpatients: 46 patients suffering from headache only on weekends (23 males and 23 females) and 58 matched common migraineurs (26 males and 32 females) with no weekend predilection. The psychological assessment was performed using the following psychometric tools: MMPI, BDI, STAIX1-X2. A clinical assessment of each patient was also carried out. Significant differences were found after statistically analyzing the test results. Most of the MMPI scales were found to be more elevated in both male and female weekend headache sufferers. From a clinical point of view, the weekend headache attacks proved to be similar to those of common migraine, but with a significantly higher incidence of concomitant symptoms. Our study confirms the important role that psychological factors play in the pathogenesis and clinical development of migraine and leads us to conclude that a psychic tension component is associated with the vascular one in weekend headache.     

Migraine aura without headache: benign, but a diagnosis of exclusion

Migraine aura without headache should be considered as a diagnosis in anyone who has recurrent episodes of transient symptoms, especially those that are visual or neurological or involve vertigo. Visual and neurological symptoms due to migraine are not unusual and most commonly occur in older persons with a history of migraine headaches. Migraine aura without headache should be diagnosed only when transient ischemic attack and seizure disorders have been excluded.     

Migraine: An Alternative in the Diagnosis of Unclassified Vertigo

SYNOPSIS
Vertigo and unsteadiness are frequent reasons for medical consultation. In some cases, these symptoms remain unclassified. The association of equilibrium disorders with migraine is often mentioned in literature.
Seventy-two cases of unclassified vertigo were studied in order to ascertain the prevalence of migraine in patients affected by recurring episodes of vertigo from undetermined causes, and attempting to establish a possible relationship with migraine. Characteristics of the vertigo and the headache, were evaluated by clinical history and examination, electronystagmogram (ENG), electroencephalogram (EEG), computerized tomography scanning (CT) and/or magnetic resonance imaging (MRI). In the group of patients studied 50% suffered from headache, and 32.8% fulfilled the diagnostic criteria of migraine. Results suggest that only a thorough clinical history would be able to give enough information to establish the diagnosis of migraine in these patients.
These observations imply an alternative diagnosis to be taken into account when a case of unclassified vertigo is evaluated.     

Traumatisch ausgelöste Migräneattacken (TAMA) Eine Literaturübersicht

In children and young adults migraine attacks can be triggered by mild head injury. The literature on this syndrome was surveyed and 50 case reports found to meet the latest criteria of classification requiring at least two similar attacks for diagnosis of migraine (except for common migraine which was excluded from review). 33 subjects had at least one trauma-triggered attack and one identical or similar spontaneous attack, 17 cases at least two similar or identical trauma triggered attacks. An analysis of all cases showed the following features: The symptoms of migraine mostly start with a latency between one and thirty minutes after the injury and dissolve within one day. First attacks without mention of headache were mainly found in children younger than 8 years. Trauma-triggered migraine attacks are well documented for familial hemiplegic migraine, migraine attacks with hemispheric symptoms and attacks with disturbances of consciousness, while the view that posttraumatic transient cortical blindness and transient global amnesia are migraine attacks is insufficiently supported. A hereditary predisposition for a traumatic trigger mechanism seems to be present at least in familial hemiplegic migraine. Nosologic relations to syndromes of secondary neurological deterioration after mild head injury in childhood are discussed.     

TCD对175例中老年发作性眩晕的诊断意义

本文对１７５例中老年发作性眩晕的临床，ＣＴ、ＭＲＩ和ＴＣＤ进行了检测。并结合１７７名同年龄组健康人正常值进行对比分析。１７５例中，男１０２例，女７３例，平均年龄５９．５岁。分四组：１颈性晕组（５６人）合并明显的颈椎病。２、Ｖ－ＢＡＴＩＡ组（４２人）有眩晕及局灶神经证，２４小时内消失。３、Ｖ－ＢＡ系统脑梗塞组（６２人）。４、颈性眩晕并ＴＣＤ转颈组（１５人）。ＴＣＤ，总异常率６３．２％；有神经征阳８１     

Treating early versus treating mild: timing of migraine prescription medications among patients with diagnosed migraine

INTRODUCTION: Although research suggests that early treatment of migraine headache when the pain is mild results in better outcomes for patients, many patients delay taking their acute-migraine medication until their headaches are moderate or severe. Understanding when and why patients use their migraine medications is an important first step to improve migraine management. METHODS: A prospective observational study, conducted at a major national retail pharmacy chain with stores across the United States between April 2001 and November 2002, enrolled men and women between 18 and 55 years of age with a physician diagnosis of migraine with or without aura. Baseline data on 690 patients included patient demographics, migraine history, medication use, tendency to avoid or delay treatment of a migraine attack, and reasons for delaying treatment. Reasons for delaying treatment were assessed via a checklist of nine potential reasons. In the follow-up survey completed after treatment of the next migraine attack, patients reported the timing of medication use in relation to pain onset and the severity of the migraine headache at the time they took the medication. RESULTS: Despite the severity of their typical migraine attacks, approximately 49% of the respondents answered, "yes" to the question, "Do you often avoid or delay taking your migraine medications when you start to experience a migraine attack?" The two most common rationales for avoiding or delaying treatment were "wanting to wait and see if it is really a migraine attack" (69%) followed by "only want to take medications if it is a severe attack" (46%). In the follow-up survey, regardless of medication used, about 85% of patients did not treat their next migraine attack until the headache pain was moderate or severe, although 74% treated within 1 hour of pain onset. CONCLUSION: These results suggest that patients with migraine often delay their treatment until they have identified their attack as a migraine. In addition, while many patients treated their follow-up headache early, they did not treat when the pain was mild. This suggests that there is an opportunity for physicians to educate their migraine patients on how to differentiate migraine from other headache types and about when and how to use their acute-migraine medication.     

Benign paroxysmal vertigo in childhood: a long-term follow-up

Benign paroxysmal vertigo in children is characterized by sudden attacks of vertigo lasting seconds or minutes. During the attack, the child has nystagmus and is unable to stand without support. Initially, the attacks are frequent, later slowly disappearing. Nineteen children who were diagnosed in 1975–1981 participated in a follow-up study. Sixteen of them were examined with audiometry and electronystagmography. Age at onset was from 5 months to 8 years, and the symptoms disappeared after 3 months to 8 years. The follow-up was performed 13 to 20 years after diagnosis. Twenty-one percent developed migraine which is somewhat more than in a normal population of this age. Thirty-nine percent had a family history of migraine which is a figure considerably lower than in a migraine population. None still had vertigo or a balance disorder. Our conclusion is that benign paroxysmal vertigo has a favorable outcome, and it is not a general precursor of migraine.     

Headaches related to triptans therapy in patients of migrainous vertigo

Dizziness and vertigo are frequently reported by patients with migraine. In migrainous vertigo (MV), vertigo is causally related to migraine. Patients of MV usually have an attenuated or absent headache with their vertigo as compared with their usual headache of migraine. Here we report three female patients of MV in which administration of triptan was associated with induction (two patients) or exacerbation (one patient) of headache with disappearance of vertigo. We suggest that headache and vertigo of migraine may be inversely related to each other and suppression of one may induce or aggravate the other.     

The movement-related potential in children with migraine and tension-type headache

Migraine is characterized by an elevated contingent negative variation (CNV) in adults and children. In the present study the movement-related potential preceding self-initiated movements, the Bereitschaftspotential, was investigated in 30 children (mean age 12 years) who were suffering from migraine and tension-type headache and in 16 healthy age-matched controls. Children pressed a button 80 times with the right index finger while movement-related potentials were recorded from frontal and central electrodes. Whereas healthy children evidenced positive movement-related potentials at left and midline positions, children with migraine and tension-type headache showed negative movement-related potentials at midline leads without lateralization. Negativity was even more pronounced in cases of migraine with than without aura symptoms.     

Hemodynamic findings in migraine patients on transcranial Doppler sonography.

Forty migraine patients were examined by means of 3D-transcranial Doppler scanning (TCD). The complete circle of Willis was investigated in all patients during headache-free intervals. TCD investigations were repeated in 10 patients during a migraine attack, in one patient twice. Based on the diagnostic criteria of the "headache classification committee of the international headache society" 23 patients were assigned to a "migraine without aura" group and 17 to a "migraine with aura" group. Twenty age-matched volunteers, not suffering from headache or any vascular disease, served as a control group. No significant differences were detected between the hemodynamic data of the control group and the migraine groups both with respect to the headache-free interval and the attack. No hemodynamic changes in keeping with the pathophysiologic hypothesis of vasospasm were found in the proximal segments of the basal cerebral arteries.