Spontaneous vertigo and headache: Endolymphatic hydrops or migraine? - Original Article

Ear, Nose & Throat Journal, Dec, 2001 by Thomas E. Boismier, Michael J. Disher

Abstract

We undertook a study to assess whether patients who had both spontaneous vertigo and headache would respond to treatment for endolymphatic hydrops rather than treatment for migraine. We also attempted to discover if there were any individual characteristics that might predict which patients with an equivocal history and symptoms would be more likely to have either of the two conditions as opposed to the other. All patients were initially treated for endolymphatic hydrops with sodium restriction and increased water intake. Response to treatment was assessed by three tools: the Dizziness Handicap Inventory, a symptom severity scale, and a disability scale. Patients who did not respond to treatment for endolymphatic hydrops were switched to treatment for migraine. At the first follow-up period, 23 patients were available for analysis by telephone survey. According to data obtained by the three assessment tools, 14 patients (60.9%) improved after initial therapy and six (26.1%) improved following subsequent migraine treatment; the remaining three patients (13.0%) did not comply with their initial treatment regimen, and they showed no improvement. Although no statistically significant conclusions can be drawn because of the small sample size, there were trends to suggest that certain demographic, clinical, and objective-testing characteristics might predict which patients are likely to have one of these two conditions as opposed to the other. We conclude that a stepwise approach to treatment, beginning with therapy for endolymphatic hydrops, is an appropriate strategy. Also, the fact that no improvement was seen among the three patients who did not comply suggests that improvement is indeed the result of treatment rather than simply a function of the passage of time.

Introduction

Patients with vertigo often describe symptom complexes that do not fit neatly into textbook diagnostic categories. In particular, a diagnosis of endolymphatic hydrops can be uncertain in those patients who have a history of migraine, aura, and/or features of migraine during vertigo attacks. In this article, we describe our study of 46 patients with equivocal vertiginous symptoms who were initially treated for endolymphatic hydrops.

Patients and methods

During the 18-month period between Nov. 1, 1997, and April 30, 1999, our balance center evaluated 770 patients who had symptoms of vertigo. We obtained each patient's medical history (including a full headache history) and a detailed description of vertigo symptoms. Our assessment included an audiogram, balance testing, and an examination by an otolaryngologist or neurotologist. Site-of-lesion testing--either brainstem evoked response or contrast-enhanced magnetic resonance imaging of the internal auditory canals--was performed when appropriate. Laboratory studies included measurements of FTA-ABS, thyroid-stimulating hormone, and complete blood count.

Balance testing included electronystagmography, the Hallpike maneuver, water calorics, and recordings of spontaneous, positional, and post-head-shaking nystagmus. Rotation tests included assessment of phase, gain, and symmetry at six frequencies of sinusoidal rotation (from 0.01 through 0.64 Hz at 50[degrees]/sec peak velocity), high-peak-velocity sinusoids (0.32 Hz at 250[degrees]/sec peak velocity), rotational step tests, and visual-vestibular fixation and enhancement tests. Computerized oculomotility tests included assessments of multifrequency sinusoidal pursuit from 0.2 through 0.7 Hz, full-field optokinetics, semirandom saccades (both conjugate and individual eye recordings), lateral and vertical stationary gaze, and antisaccades. Among the postural control tests were observations of casual gait, the modified Fukuda stepping test, (1) and either computerized dynamic posturography or the modified Clinical Test of Sensory Integration in Balance. (2) All recordings of eye movement were made with standard electro-oculographic electrodes.

The degrees of symptom severity and disability were assessed by the use of three tools: the Dizziness Handicap Inventory (DHI), (3) a 0-to-10-point symptom severity scale (response to the question, On a scale from 0 to 10--where 0 is no dizziness or balance problems at all and 10 is the worst dizziness or balance symptoms you can possibly imagine--what number would you give yourself for the way you've been feeling lately?), and the 0-to-5-point disability scale (0 = no disability; 5 = severe, long-term disability) described by Shepard et al. (4) Each patient was counseled by the lead author (T.E.B.), who explained the differential diagnoses and the progression of treatment from therapy for endolymphatic hydrops to therapy for migraine-associated vertigo. Patients were also given written educational materials.

Based on the results of these batteries of tests, we gave 46 patients (6.0%) a differential diagnosis of endolymphatic hydrops versus migraine-associated vertigo. (5) The history and physical examination of these patients did not suggest any of the proposed etiologies for endolymphatic hydrops (e.g., allergy or autoimmune processes), nor was the audiogram suggestive of classic Meniere's disease.