Vestibular Rehabilitation an Effective Treatment for Vestibular Migraine

In a study recently published in Frontiers in Neurology, vestibular rehabilitation was found to ameliorate headache, dizziness, and psychological factors in patients with vestibular migraine or a combination of tension-type headache and dizziness.¹

Migraine can be associated with vestibular symptoms (eg, dizziness, vertigo), and vestibular migraine refers to “vestibular symptoms that are causally related to migraine.”^2,3 Diagnostic criteria for vestibular migraine were formulated in 2012 by the Committee for the Classification of Vestibular Disorders of the Bárány Society and the Migraine Classification Subcommittee of the International Headache Society.⁴ A diagnosis of vestibular migraine, for which no biomarkers are currently available, requires “recurrent vestibular symptoms, a history of migraine, a temporal association between vestibular symptoms and migraine symptoms and exclusion of other causes of vestibular symptoms.”⁴

Additive effects of nociceptive and vestibular information in pre-thalamic and pre-parabrachial pathways are thought to contribute to vestibular migraine development.⁵

In the current study, the researchers based their clinical diagnosis of vestibular migraine on aforementioned guidelines, which were added to the appendix of the International Classification of Headache Disorders (ICHD)-3 β version in 2013,⁶ stipulating that in order to establish a vestibular migraine diagnosis, patients need to experience a minimum of 5 episodes with moderate to severe vestibular symptoms lasting from 5 to 72 minutes (an addendum to the guidelines), and a minimum of half of the episodes must be associated with ≥1 migrainous feature: headache (with 2 out of 4 of the following aspects: unilateral location, pulsing quality, moderate to severe intensity, worsened by physical activity); photophobia and phonophobia; and/or visual aura. In addition, a history of migraine with or without aura and the absence of an alternate ICHD-3 or vestibular disorder diagnosis are required to establish a vestibular migraine diagnosis.

Vestibular rehabilitation has shown effectiveness in treating vestibular dysfunction-related dizziness.⁷ The researchers of the current study sought to investigate whether vestibular rehabilitation may also alleviate vestibular migraine-associated headache, dizziness, and psychological factors.

A total of 251 patients (77.7% women; mean age, 62.64 ± 16.40 years) who consulted the department of otorhinolaryngology of the National Tokyo Medical Center  between February 2015 and August 2016, had reported persistent dizziness for more than 3 months despite treatment (ie, daily betahistine 36 mg for 2 to 4 weeks, daily exercise, adequate sleep, and stress reduction), and were older than age 20 and literate were enrolled as inpatients for the treatment of their dizziness.

Among study participants who had a Headache Impact Test (HIT-6) score ≥50, 28 had vestibular migraine (100% women), and 79 had tension-type headache (79.7% women). Patients with HIT-6 scores ≤49 were categorized as “non-headache” (n=144, 72.2% women) and included 4 participants with a diagnosed vestibular migraine but no headache.

Vestibular rehabilitation consisted of vestibulo-ocular and vestibulo-spinal training in groups of 8 to 10 patients conducted over a period of 5 days. Patients were also instructed on how to conduct this program on their own upon the end of the treatment period. Vestibulo-ocular training comprised 7 exercises, each repeated 20 times: quick horizontal and vertical eye movements, eye tracking in horizontal and vertical directions, horizontal and vertical head shaking with gazing at a fixed target, and oblique head tilting with gazing at a fixed target. Vestibulo-spinal training consisted of 8 static exercises (standing up and sitting down with eyes open [3 times] or closed [3 times], standing with eyes closed and feet open [20 s] or closed [20 s], standing with tandem gait with right foot [20 s] or left foot [20 s] in front, one-leg stand on the right [20 s] or left foot [20 s]; and 5 dynamic exercises (180° turn to the left [3 times] or the right [3 times], walking with tandem gait [10 min], walking with horizontal [10 min] or vertical head shaking [10 min]).

Study participants were asked to fill out questionnaires at 3 time points: on the day they were hospitalized (T1) and 1 and 4 months following the inpatient treatment (T2 and T3). These questionnaires aimed to determine the impact of headaches (the study’s principal outcome) and dizziness on quality of life (HIT-6  and Dizziness Handicap Inventory [DHI] tests, respectively), headache and dizziness frequency, anxiety (Hospital Anxiety and Depression Scale [HADS]), catastrophizing (Somatosensory Catastrophizing Scale [SSCS]), and dizziness severity (Gravity Center Fluctuation Measurement [GCFM]).

Patients with vestibular migraine and tension-type headache had higher HIT-6 and DHI scores and lower headache frequency than participants in the nonheadache group at all 3 time points (P <.0001 for all; DHI scores were higher in vestibular migraine patients vs nonheadache patients only at T1), and these scores decreased at T2 and T3 compared with T1 (P <.0001 for all).

Dizziness frequency was reduced over time (P <.0001), but no significant difference was found between groups. A significant effect of both group and time was found for both HADS and SSCS scores, and these scores were lower at T2 and T3 compared with T1. Measures of center of gravity fluctuations also indicated an effect of time.

The researchers conclude that “Vestibular rehabilitation contributed to the improvement of headache both in patients with [vestibular migraine] and patients with dizziness and tension-type headache, in addition to the improvement of dizziness and psychological factors. The improvement in dizziness following vestibular rehabilitation contributed to the improvement in headache more prominently in the [vestibular migraine] group in comparison with the tension-type headache group.”

Limitations

• Study participants in the vestibular migraine group were few (n=28) and all women
• Compliance to rehabilitation program was confirmed verbally, and no recordkeeping was asked of study participants
• Initial group assignment was based on HIT-6 scores vs headache severity data
• No control group was included in the study

Follow @ClinicalPainAdv

References

1. Sugaya N, Arai M, Goto F. Is the headache in patients with vestibular migraine attenuated by vestibular rehabilitation? Front Neurol. 2017;8:124.
2. Vuković V, Plavec D, Galinović I, Lovrencić-Huzjan A, Budisić M, Demarin V. Prevalence of vertigo, dizziness, and migrainous vertigo in patients with migraine. Headache. 2007;47(10):1427-1435.
3. Dieterich M, Obermann M, Celebisoy N. Vestibular migraine: the most frequent entity of episodic vertigo. J Neurol. 2016;263(Suppl 1):S82-S89.
4. Lempert T, Olesen J, Furman J, et al. Vestibular migraine: diagnostic criteria. J Vestib Res. 2012;22(4):167-172.
5. Balaban CD. Migraine, vertigo and migrainous vertigo: links between vestibular and pain mechanisms. J Vestib Res. 2011;21(6):315-321.
6. Kim BS, Moon HS, Sohn JH, et al. Short-term diagnostic stability of probable headache disorders based on the International Classification of Headache Disorders, 3rd edition beta version, in first-visit patients: a multicenter follow-up study. J Headache Pain. 2016;17:13.
7. Cohen HS, Kimball KT. Increased independence and decreased vertigo after vestibular rehabilitation. Otolaryngol Head Neck Surg. 2003;128(1):60-70.