Orofacial Pain and Headache, Second Edition
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7 Otolaryngologic Aspects of Orofacial Pain Table 7-8 Diagnostic criteria for vestibular migraine Diagnostic criteria Notes A. At least five episodes fulfilling criteria C and D B. A current or past history of Code also for the underlying migraine diagnosis. 1.1 Migraine without aura or 1.2 Migraine with aura C. Vestibular symptoms of Vestibular symptoms, as defined by the Bárány Society’s Classification of moderate or severe intensity, Vestibular Symptoms and qualifying for a diagnosis of A1.6.5 Vestibular lasting between 5 minutes migraine, include: and 72 hours a. Spontaneous vertigo: i. Internal vertigo (a false sensation of self motion) ii. External vertigo (a false sensation that the visual surround is spinning or flowing) b. Positional vertigo, occurring after a change of head position c. Visually induced vertigo, triggered by a complex or large moving visual stimulus d. Head motion–induced vertigo, occurring during head motion e. Head motion–induced dizziness with nausea (dizziness is characterized by a sensation of disturbed spatial orientation; other forms of dizziness are currently not included in the classification of vestibular migraine) Vestibular symptoms are rated moderate when they interfere with but do not prevent daily activities and severe when daily activities cannot be continued. Duration of episodes is highly variable. About 30% of patients have episodes lasting minutes, 30% have attacks for hours, and another 30% have attacks over several days. The remaining 10% have attacks lasting seconds only, which tend to occur repeatedly during head motion, visual stimulation, or after changes of head position. In these patients, episode duration is defined as the total period during which short attacks recur. At the other end of the spectrum, there are patients who may take 4 weeks to recover fully from an episode. However, the core episode rarely exceeds 72 hours. D. At least 50% of episodes One symptom is sufficient during a single episode. Different symptoms may are associated with at least occur during different episodes. Associated symptoms may occur before, one of the following three during or after the vestibular symptoms. migrainous features: Phonophobia is defined as sound-induced discomfort. It is a transient and 1. Headache with at least bilateral phenomenon that must be differentiated from recruitment, which is two of the following four often unilateral and persistent. Recruitment leads to an enhanced perception characteristics: and often distortion of loud sounds in an ear with decreased hearing. a. Unilateral location b. Pulsating quality Visual auras are characterized by bright scaintillating lights or zigzag lines, c. Moderate or severe often with a scotoma that interferes with reading. Visual auras typically expand intensity over 5–20 minutes and last for less than 60 minutes. They are often, but not d. Aggravation by routine always restricted to one hemifield. Other types of migraine aura, for example physical activity somatosensory or dysphasic aura, are not included as diagnostic criteria 2. Photophobia and because their phenomenology is less specific and most patients also have phonophobia visual auras. 3. Visual aura E. Not better accounted for by History and physical examinations do not suggest another vestibular disorder another ICHD-3 diagnosis or such a disorder has been considered but ruled out by appropriate or by another vestibular investigations or such a disorder is present as a comorbid or independent disorder condition, but episodes can be clearly differentiated. Migraine attacks may be induced by vestibular stimulation. Therefore, the differential diagnosis should include other vestibular disorders complicated by superimposed migraine attacks. 190 Vestibular Syndromes Related to Orofacial Pain or Structures tion, and susceptibility to motion sickness may jects, indicating that those with migraine have a be associated with vestibular migraine. Howev- lowered threshold for crosstalk between these er, they also occur with various other vestibular neighboring brainstem structures.95 disorders, so they are not included as diagnos- Migraine is more common in patients with tic criteria. Ménière’s disease than in healthy control sub- The prevalence of vestibular migraine is vari- jects. Many patients with features of both able and probably underdiagnosed, as shown Ménière’s disease and vestibular migraine have by a study from a dizziness clinic in Switzer- been reported. In fact, migraine and Ménière’s land, where vestibular migraine accounted for disease can be inherited as a symptom clus- 20.2% of the diagnoses in young patients but ter. Fluctuating hearing loss, tinnitus, and au- was suspected by the referring physicians in ral pressure may occur in vestibular migraine, only 1.8%.92 In a community-based sample but hearing loss does not progress to profound of middle-aged women in Taiwan, vestibular levels. Similarly, migraine headaches, photo- migraine was identified in 5%, and in 30% of phobia, and even migraine auras are common all women with migraine.93 Vestibular migraine during attacks of Ménière’s disease. The patho- has a female preponderance, and the reported physiologic relationship between vestibular female-to-male ratio is between 1.5 and 5 to 1.88 migraine and Ménière’s disease remains uncer- Familial occurrence is not uncommon, probably tain. In the first year after onset of symptoms, based on an autosomal-dominant pattern of in- differentiation between them may be challeng- heritance with decreased penetrance in men.94 ing, as Ménière’s disease can be monosymp- In most patients, migraine begins earlier in life tomatic with only vestibular symptoms in the than vestibular migraine. Not infrequently, mi- early stages of the disease. When the criteria for graine headaches are replaced by vertigo at- Ménière’s disease are met, particularly hearing tacks in women around menopause. loss as documented by audiometry, Ménière’s Patients with vestibular migraine typically disease should be diagnosed, even when mi- report spontaneous or positional vertigo. Some graine symptoms occur during the vestibular experience a sequence of spontaneous vertigo attacks. Only patients who have two different transforming into positional vertigo after several types of attacks, one fulfilling the criteria for ves- hours or days. This positional vertigo is distinct tibular migraine and the other for Ménière’s dis- from benign paroxysmal positional vertigo with ease, should be diagnosed with both disorders. regard to duration of individual attacks (often The therapeutic recommendations for ves- as long as the head position is maintained in tibular migraine are currently based on the treat- vestibular migraine versus seconds only in be- ment guidelines for migraine (see chapter 10). nign paroxysmal positional vertigo), duration of Zolmitriptan is recommended for acute vestibu- symptomatic episodes (minutes to days in ves- lar migraine.96 Non-pharmaceutical approaches tibular migraine versus weeks in benign parox- in the treatment of vestibular migraine should ysmal positional vertigo), and nystagmus find- not be neglected and may be even more effec- ings. Vertigo can precede headache, as would tive than drugs in individual patients. A thorough be typical for an aura; may begin with headache; explanation of the migraine origin of the attacks or may appear late in the headache phase. can relieve unnecessary fears. Avoidance of Auditory symptoms, including hearing loss, identified triggers, regular sleep, regular meals, tinnitus, and aural pressure have been reported and exercise have a firm place in migraine pro- in up to 38% patients with vestibular migraine.88 phylaxis. Selected patients, particularly those Genetic and neural mechanisms have been with persistent symptoms between attacks, described for vestibular migraine. The only hy- may profit from vestibular rehabilitation.97 pothesis that is actually based on a human ex- perimental model of vestibular migraine relates to the known reciprocal connections between Mastication-induced vertigo the trigeminal and vestibular nuclei. Trigeminal activation by painful electrical stimulation of the and nystagmus forehead produced spontaneous nystagmus in Various maneuvers may trigger vertigo and nys- patients with migraine but not in control sub- tagmus according to the pathology involved. 191 7 Otolaryngologic Aspects of Orofacial Pain Although reciprocal connections exist between 5. Harvey H. Diagnosing referred otalgia: The ten Ts. the trigeminal and vestibular systems, induc- Cranio 1992;10:333–334. 6. Yanagisawa K, Kveton JF. Referred otalgia. Am J tion of dizziness or oscillopsia by mastication Otolaryngol 1992;13:323–327. has been reported only as a mechanical or vas- 7. Kim DS, Cheang P, Dover S, Drake-Lee AB. Dental cular steal phenomenon.98–100 otalgia. J Laryngol Otol 2007;121:1129–1134. Mastication-induced vertigo and nystagmus 8. Wazen JJ. Referred otalgia. Otolaryngol Clin N Am are rare phenomena. Park et al101 determined in- 1989;22:1205–1215. 9. Jaber JJ, Leonetti JP, Lawrason AE, Feustel PJ. Cer- duction or modulation of nystagmus in two index vical spine causes for referred Otaligia. Otolaryngol patients with mastication-induced vertigo, 12 Head Neck Surg 2008;138:479–85. healthy control subjects, and 52 additional pa- 10. Nestor JJ, Ngo LK. Incidence of facial pain caused tients with peripheral or central vestibulopathy by lung cancer. Otolaryngol Head Neck Surg 1994;111(1):155-156. during their acute or compensated phase. Both 11.