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ARTICLES: H. Neuhauser, M. Leopold, M. von Brevern, G. Arnold, and T. Lempert The interrelations of migraine, vertigo, and migrainous vertigo Neurology 2001; 56: 436-441 [Abstract] [Full text] [PDF]

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Reply to Hochman and Preter

Hannelore K Neuhauser, Thomas Lempert   (10 June 2001)

The interrelations of migraine, vertigo, and migrainous vertigo

Maurice Preter   (10 June 2001)

The interrelations of migraine, vertigo, and migrainous vertigo

M Seth Hochman   (10 June 2001)

Reply to Hochman and Preter 10 June 2001
Hannelore K Neuhauser Neurologische Poliklinik, Berlin, Thomas Lempert Send Correspondence to journal: Re: Reply to Hochman and Preter hanne.neuhauser{at}charite.de Hannelore K Neuhauser, et al.	We thank Dr. Hochman for bringing up the issue of therapy of migrainous vertigo. The existing evidence consists of a small case series of patients who responded favourably to prophylactic antimigraine therapy with propranolol (7) metoprolol(8), pizotifen (9), ergotamine (7,8) or flunarizine. (8) However, there have been no randomized clinical trials. In a recent retrospective study, migraine patients with a history of dizziness or vertigo were asked to rate the therapeutic response both of headaches and dizziness/vertigo to antimigrainous drugs. (10) A subgroup of seven migraine patients with a history of vertigo took sumatriptan and considered it not only effective in ameliorating headaches but also for treating vertigo. The study has several methodologic problems but corresponds to our experience that triptans can be effective for aborting migrainous vertigo. However, not all patients with definite migrainous vertigo in our study are candidates for triptans since, apart from contraindications for triptans, one must consider that oral triptans are not a reasonable choice for attacks lasting less than one hour. Subcutaneous or nasal administration may be an option in some cases. Overall, we think that the existing evidence can justify a therapeutic trial in individual patients, but randomized clinical trials are needed to clarify the role of triptans in the treatment of migrainous vertigo. Dr. Preter suggests that we should have taken into account psychiatric comorbidity of migraine, namely panic disorder. However, he does not explain how the comorbidity of panic disorder and migraine might affect the results of our study. The interrelations of panic disorder with dizziness and vertigo are complex. On the one hand, nonvestibular dizziness may be a symptom of panic disorder, on the other hand, there is an increased comorbidity of vestibular symptoms and panic disorder. (11) This, however, should not lead to the conclusion that panic disorder itself can present with true vertigo. Therefore, an important aspect in the differentiation of definite/probable migrainous vertigo and panic disorder is the vestibular vs. nonvestibular type of dizziness as defined in our proposed diagnostic criteria. One of the main results of our study is that patients with dizziness/vertigo have a higher migraine prevalence than controls. Dr. Preter seems to suggest that the high prevalence of migraine in the dizziness clinic group may be attributed to a subgroup of patients with psychogenic dizziness who may have an increased prevalence of migraine. However, in our dizziness clinic group, contrary to Dr. Preter’s calculation, patients with vestibular symptoms contribute more to the high migraine prevalence than patients with nonvestibular dizziness, including panic disorder, as can be seen in Table 2 of our original paper. 7. Harker LA, Rassekh CH. Episodic vertigo in basilar artery migraine. Otolaryngol Head Neck Surg 1987;96:239-250. 8. Dieterich M, Brandt T. Episodic vertigo related to migraine (90 cases): vestibular migraine? J Neurol 1999;246:883-892. 9. Behan PO, Carlin J. Benign recurrent vertigo. In: Rose FC ed. Advances in migraine research and therapy. New York : Raven, 1982:49-55. 10. Bikhazi P, Jackson C, Ruckenstein MJ. Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness. Am J Otol 1997;18:350-354. 11. Simon NM, Pollack MH, Tuby KS, Stern TA. Dizziness and panic disorder: a review of the association between vestibular dysfunction and anxiety. Ann Clin Psychiatry 1998;10:75-80
The interrelations of migraine, vertigo, and migrainous vertigo 10 June 2001
Maurice Preter, Assistant Professor of Psychiatry and Neurology University of Mississippi Medical Center Send Correspondence to journal: Re: The interrelations of migraine, vertigo, and migrainous vertigo mpreter{at}psychiatry.umsmed.edu Maurice Preter	To the Editor: I read Neuhauser et al's study on "The interrelations of migraine, vertigo, and migrainous vertigo" with interest. (1) . The authors correctly point out the diagnostic and nosologic complexities of “migrainous vertigo”. It was surprising however that their discussion did not take into account the psychiatric comorbidity of migraine, namely panic disorder. Simple inspection of the data presented in Table 2, and adding up the number of patients comprised in the four most problematic nosologic categories (psychogenic dizziness, vestibulopathy of unknown origin, probable migrainous vertigo, and undetermined) shows that 75% of all patients likely carried a “functional” diagnosis. The association between migraine and panic disorder is epidemiologically well–established and clinically relevant (2). Data recently published in this journal show that this comorbidity of panic disorder may also apply to severe headaches other than migraine (3). Bidirectionality suggests that the migraine-panic association is unlikely to be merely coincidental (4) and that shared environmental or genetic factors are involved. Any diagnosis of migraine should heighten the suspicion of comorbid panic disorder (3). Conversely, although classical panic disorder is characterized by prominent dyspnea (5), a number of patients may present with atypical symptoms, such as gastrointestinal and vestibular ones, including true vertigo (6). These panic subtypes, especially if undiagnosed are likely to contribute to the high chronic morbidity of panic disorder, and of the possibly related condition, migraine headache. References: 1. Neuhauser H, Leopold M, von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo, and migrainous vertigo. Neurology 2001;56: 436-441. 2. Silberstein SD, Lipton RB, Breslau N. Migraine: association with personality characteristics and psychopathology. Cephalalgia. 1995;15:358- 369. 3. Breslau N, Schultz LR, Stewart WF, Lipton R, Welch KM. Headache types and panic disorder: directionality and specificity. Neurology 2001;56:350- 354. 4. Preter M, Klein DF: Panic disorder and the suffocation false alarm theory: Current state of knowledge and further implications for neurobiologic theory testing. In: Bellodi L, Perna G, eds. The panic respiration connection. Milan 1998. 5. Klein DF. False suffocation alarms, spontaneous panics, and related conditions. An integrative hypothesis. Arch Gen Psychiatry 1993;50:306- 317. 6. Jacob RG. Panic disorder and the vestibular system. Psychiatr Clin North Am. 1988;11:361-374.
The interrelations of migraine, vertigo, and migrainous vertigo 10 June 2001
M Seth Hochman Miami Center for Neurogical Diseases Send Correspondence to journal: Re: The interrelations of migraine, vertigo, and migrainous vertigo kathy_pieper{at}urmc.rochester.edu M Seth Hochman	The authors report that 30 of 33 patients with definite migrainous vertigo did not fulfill the IHS criteria for basilar migraine. Were these 30 patients, and are other patients with migrainous vertigo without additional symptoms of brainstem dysfunction, candidates for triptans, which are contra-indicated in basilar migraine? If so, do the authors have experience whether triptans are effective for migrainous vertigo? Reference 1. Neuhauser H, Leopold M, Von Brevern M, Arnold G, Lempert T. The interrelations of migraine, vertigo and migrainous vertigo. Neurology 2001;56:436-441.