Recent changes to the International Classification of Headache Disorders (ICHD) made vestibular migraine a distinct condition, and clinical trials are underway to develop targeted therapies.
Richard A. Roberts, Ph.D., an audiologist at Vanderbilt’s Bill Wilkerson Center, recently launched a clinical trial to determine the effects of lifestyle modifications on this common cause of dizziness. “Although lifestyle modifications like a migraine diet are often provided to patients with vestibular migraine, there hasn’t really been a systematic investigation with patients defined using the new criteria,” he said.
Prone to Misdiagnosis
Vestibular migraine can be enigmatic, and even neurology and ENT specialists may not recognize its presentation, Roberts said. There is often significant overlap with other vestibular disorders, such as Ménière’s disease.
“With vestibular migraine, there may be no headache at all, or it may not be temporally correlated to dizziness. We only see correlation about half the time. And, when present, vestibular headache is not always the intense headache most people think characterizes migraine.”
“Vestibular headache is not always the intense headache most people think characterizes migraine.”
Roberts says vestibular migraine patients who present without headache are prone to misdiagnosis. “Without headache, physicians may eliminate vestibular migraine from the differential.” Studies have shown this certainly occurs with frontline healthcare providers.
A Comprehensive Approach
The trial has strict enrollment criteria to identify 40 adults who meet the ICHD requirements for vestibular migraine. Participants will receive information about lifestyle changes that have proven beneficial in other types of migraine.
For 60 days, they will be asked to make lifestyle changes across four areas: eliminate food and beverage triggers, improve restful sleep, increase exercise, and eat at the same time each day. Roberts is collaborating with Ken Watford, D.N.P., assistant professor of clinical otolaryngology at Vanderbilt on the trial. Watford is diagnosing the patients, and will also counsel participants and provide written suggestions, such as examples of a migraine diet and a walking exercise protocol.
“We know eliminating dietary triggers improves symptoms in 60 to 90 percent of people with other migraines. Likewise, treating insomnia can half headache frequency in migraineurs,” Roberts said. “We assume patients with vestibular migraine will respond similarly but that has not been proven. We really don’t know which are specific vestibular migraine triggers. We’re eliminating all of them for 60 days to see if we can also improve symptoms in these patients.”
The researchers will track vestibular migraine symptoms throughout the trial using participant adherence self-assessments and tools developed by Gary P. Jacobson, Ph.D., professor of hearing and speech sciences at Vanderbilt.
Jacobson and colleagues from the Vanderbilt Balance Disorders Lab also developed the Dizziness Symptom Profile. This 31-item patient self-report questionnaire helps clinicians develop a differential for vestibular disorders and was found to be in agreement with ear specialists 95 percent of the time for the diagnosis of vestibular migraine.
The new vestibular migraine trial will help identify lifestyle modifications associated with both symptom relief and strong adherence. Some of the study participants may see dramatic improvements from the lifestyle modifications alone, while others may later require pharmacologic intervention.
In future studies, Roberts’ team plan to combine the most promising vestibular migraine lifestyle modifications with pharmacologic interventions.
“We’re working toward a comprehensive therapeutic approach.”
Said Roberts, “Other migraine studies show anywhere from a 25 to 60 percent improvement in symptoms from pharmacy alone. But when you combine pharmacologic management with lifestyle modifications like a migraine diet, this goes up to 72 to 92 percent. We’re working toward a comprehensive therapeutic approach to positively impact the majority of patients with vestibular migraine.”