Vestibular Migraine Diagnosis & Treatment Podcast with Dr. Carol Foster by the APTA

Kelley NunnMy Migraine Blog

Vestibular Migraine Symptoms, Diagnosis, and Treatment Podcast from the APTA with Dr. Carol Foster

About the APTA Podcast

From time to time, I scour the internet for informative pieces related to vestibular migraine. Earlier this week, I hit the jackpot in finding a somewhat ‘old’ podcast recording from the American Physical Therapy Association recorded in June, 2013, in which Dr. Carol Foster, Director of the Balance Laboratory at the University of Colorado Hospital, discusses all-things vestibular migraine. The interview downright knocked my socks off– Dr. Foster gave so many informative answers, some of which on topics I had never heard of! The final topic of the interview, specifically, blew me away.

Once I finished listening, I immediately wanted to share the podcast recording around, but realized that most people probably don’t have the time to listen to a 16-minute video. The information Dr. Foster provides in this podcast is just too valuable to miss out on! So, I decided to listen again, keep diligent notes, and type up a summary of the interview here, such that people can access the information quickly.

PLEASE NOTE: The content of this podcast belongs to the APTA for the Neurology Section Special Interest Groups. The interviewer asking the questions in the podcast is Ethan Hood PT, DPT, GCS– regional director for St. Luke’s Physical Therapy in New Jersey. In general, the text below is my paraphrased version of Dr. Foster’s answers to interview questions with occasional use of direct quotations.

How Common is Vestibular Migraine in the Population?

Dr. Foster: Vestibular migraine is very common in the dizziness population, accounting for at least 1/4th of dizzy patients. Migraine accounts for about 10% of the general population, and approximately 1/3 of these people also suffer from dizziness.

My input: These statistics on the general prevalence of vestibular migraine are fantastic– they paint such a clear picture of just how many people are affected by this neurological disease. I recently wrote a post, in which I discuss similar statistics in the context of the United States population, which you can find here if you’re interested!

Is A Certain Demographic Affected by (Vestibular) Migraine?

Dr. Foster: Yes. Migraine tends to affect more women than men, though men are also affected. In women, migraine tends to show an increase around puberty and menopause, as hormones seem to be a major factor in precipitating migraines.

What Are the Clinical Symptoms of Vestibular Migraine?

Dr. Foster: What you tend to see is a broad range of symptoms in the same person. This can include momentary dizziness, or spells that go on for days– all within the same person. The quality of dizziness can vary from a momentary out-of-sorts feeling to a constant rocking sensation to episodes of violent spinning.

What Are the Diagnostic Criteria for Vestibular Migriane?

Dr. Foster: “I am very open-minded in my diagnosis. There are other people who have attempted to make a criteria for it. I think you’ll miss too many doing that, because at present, we don’t have an objective test for migraine. There is nothing that you can do to prove someone has it or does not, it’s all clinically based.” The best thing doctors can do is to “maintain a strong level of suspicion.” It would be a shame for a patient not be treated, because they don’t meet a certain set of criteria, when treating them may reduce their symptoms.

The first thing you want to look for is history of migraine in the patient, all though this may not always be the case. Some patients have yet to develop classic headaches, so it’s important to look into family history. Family history is “a strong indicator that they are at risk.” … “People with migraine in general are more sensitive to vestibular stimuli. They’re more likely to develop motion sickness when they have any kind of vestibular migraine.” For example, these people can have difficulty riding in a car, or be more likely to vomit or become nauseous during a test of their balance system.

My input: As I mention in my “6 Signs Your Symptoms Could Be Vestibular Migraine” article, I believe that my not having a personal history of migraine was the biggest barrier to diagnosis that I faced. I’ve had ‘sinus headache’ migraines since I was 16, but because I lacked the ‘classic’ migraine headache, it took me months and months to reach the vestibular migraine diagnosis. I feel that it is critically important for doctors and patients to consider family history of migraine disorders when trying to diagnosis dizzy patients.

Are There Any Diagnostic Tests for (Vestibular) Migraine?

Dr. Foster: Looking at the set of symptoms a patient reports, i.e. the “symptom cluster,” is important, as testing in uncomplicated migraine should be normal. “Of course, having normal testing in the face of profound symptoms is, in fact, a strong indicator that it’s migraine.” In a typical vestibular migraine patient, hearing and balance testing should all be normal, with perhaps a slight positional nystagmus.

How Do You Treat Vestibular Migraine?

Dr. Foster: First, look at what their triggers are. Most migraines have environmental or hormonal triggers; if you can determine what their triggers are, avoiding the things that set them off can reduce the number of episodes they have. These can be hormonal, or triggers relating to weather or sensory stimuli. For example, I like to ask if the patient is taking any birth control pills or using hormones after menopause. If so, eliminating these hormones may cause symptom improvement.

Second comes medication. “I try to listen to the patient’s symptoms before picking the medications, but I do have a stable of medications that I reliably use:”

  • Nortriptyline/Amitriptyline — for “garden variety” migraineurs who have difficulty sleeping, these medications tend to help their sleep disorder.
  • Verapamil — for patients with anxiety or palpitations, or patients who fail amitriptyline/nortriptyline.
  • Topiramate/Acetazolymide — for people with more resistant migraines, or patients with auras.

How Often Do You Refer to Vestibular Therapy?

Dr. Foster: It depends entirely on the patient’s symptoms, and the type of dizziness they’re experiencing. “If the person is getting motion sick, just by walking around, this is a good candidate for physical therapy.” If they can’t go to the mall, grocery store, or watch action movies with fast, panning camera movements, then they’ll likely “respond very well to confrontation with repeated exposure to the same stimulus.”

What Are the Best Types of Vestibular Therapy For VM?

Dr. Foster: I see therapists tape striped curtains to the wall, and have their patients move their eyes back and forth– it’s less effective to do exercises for the Vestibulo Ocular Reflex (VOR), because it tends to be less effective in these patients. I prefer exercises involving balance, where patients move their heads while balancing. Opto-kinetic stimulation can also be effective— using things like checkerboards, disco balls, etc. to expose the patients to overwhelming visual stimuli.

Is There A Lack Of Research On Vestibular Migraine and Treatment For VM?

Dr. Foster: The major weakness is that we don’t have an objective test– all of our testing is clinical and subjective. There are many people called vestibular migraineurs who probably have other disorders. Until you come up with a clear cut means of identifying people with vestibular migraine, such that there is consistency across research studies, you won’t have clean data outcomes that you expect.

Are There Any New, Promising Treatments Out There For Vestibular Migraine

Dr. Foster: Yes. These involve the relationship between sleep apnea and migraine. It turns out there are many patients who have both sleep apnea and migraine. “If you have migraine and sleep apnea, you tend to have very severe migraine that cannot be treated with medication. But, it can be treated with CPAP. So, getting oxygen at night can help you get rid of your migraines.”

“The sleep apnea piece has become more and more important as the years have gone by in that probably, it accounts for a large percentage of people with migraine that doesn’t respond to medication.” Every patient, regardless of their demographics, weight, or appearance, should be asked if they snore.

Why Are Sleep Apnea and Migraine Correlated?

Dr. Foster: “Sleep apnea is a major vascular risk factor. So, the hypoxemia at night probably causes some vasoreactivity for the ensuing day. So, you’re more likely to have vasospasm and other problems, both in the heart and the head.” This can become additive with other causes of vasospasm, like migraine.

My input: This was BY FAR the most interesting piece of this interview for me; I had never heard of the relationship between sleep apnea and migraine before!! When I was at my worst symptom-wise, and was bedridden for months, I used to wake up multiple times per night unable to breathe. Since starting nortriptyline, my sleep has improved dramatically, but I wonder if sleep apnea, or breathing in general, is contributing to my migraines! Fascinating stuff!!

In Summary…

I hope you enjoyed this post, and found the information as informative and helpful as I did! If so, please share this information in any way you can– email, Facebook, Twitter, etc. The more people know about vestibular migraine diagnosis, prevalence, and treatment, the more we can reduce the unnecessary suffering experienced by migraineurs worldwide! To read more about raising awareness, check out my “Awareness Challenge” post here. Thanks for reading!!